Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 San Marino Healthcare Center during CMS and state inspections, most recent first.
Inaccurate Fall Risk documentation was found for two residents. One resident’s assessment was copied from an earlier form and did not reflect a recent fall, correct gait/balance findings, or the number of psychotropic, diuretic, antihypertensive, benzodiazepine, and narcotic medications being taken. The second resident’s assessments conflicted with each other and did not accurately show fall history, ambulation status, predisposing conditions, or the number of medications in the listed categories. Staff confirmed the forms contained incorrect documentation.
A resident with paranoid schizophrenia and major depressive disorder was identified as a wanderer and was supposed to have visual checks every 2 hours, but head count and call light check documentation was missing for multiple shifts. The resident entered another resident’s room, took a radio, and a struggle followed when the other resident tried to stop him, resulting in both residents falling and the wandering resident hitting his head. Staff stated the resident often went into other residents’ rooms and that the resident’s whereabouts were not documented as required.
Staff failed to maintain dignity for three residents by using labels and informal terms instead of names and, in one case, standing over a resident while feeding her. A CNA called one resident “my dear” during routine requests, another resident was fed while the CNA stood over her, and multiple staff referred to a third resident as “sweetie,” “girl,” and “Mama [NAME].” The residents had diagnoses including CVA-related deficits, dementia, dysphagia, ataxia, and metabolic encephalopathy, with MDSs showing dependence in multiple ADLs and, for two residents, impaired cognition.
A facility failed to keep a resident room clean and failed to maintain two residents’ manual wheelchairs in good condition. One resident’s room had used tissues on the floor and brownish stains on the wall, while staff noted the wall needed cleaning and the trash needed to be removed. Two other residents were observed with wheelchairs that had cracked, torn, or peeling armrests, and staff confirmed the equipment was not in good condition.
Two residents who needed partial moderate assistance with ADLs had care plans directing staff to assist with grooming and trimming fingernails, but observations showed long, dirty, jagged nails with debris or discoloration underneath. The SSD and an LVN stated the nails were not clean or smooth and that the facility’s ADL support and fingernail care policies were not followed.
A facility failed to keep a resident room free of electrical cord hazards and failed to adequately supervise two wandering residents. One resident with depression, seizures, and weakness had extension cords wrapped around a metal bed frame, while two residents with dementia were repeatedly observed entering other residents’ rooms. Staff acknowledged the cord setup was unsafe and stated the wandering residents needed redirection and closer supervision, but one resident had no specific wandering care plan and the other was repeatedly seen unsupervised in other residents’ rooms.
Failure to Monitor Anticoagulant Therapy for Bleeding: Two residents receiving anticoagulants were not documented as being monitored for signs and symptoms of bleeding. One resident received Heparin for DVT prophylaxis and had bruising noted, but there was no order, MAR documentation, or care plan interventions for bleeding surveillance. Another resident received Eliquis for Afib, had an anticoagulant care plan requiring shift monitoring for bleeding, but the MAR and nurses’ notes did not show that the monitoring was completed.
Improper glove use during food prep and tray line assembly was observed when a cook and kitchen staff touched a facemask, hairnet, blender, refrigerator handle, and other items while wearing the same disposable gloves and then continued handling food and serving trays without changing gloves or performing hand hygiene. The cook and kitchen staff acknowledged they should have changed gloves and washed hands between tasks, and the DTS reviewed policies requiring glove changes and handwashing to prevent contamination.
Failure to Document Antibiotic Stewardship Reviews: The facility did not complete or document antibiotic stewardship reviews for two residents receiving antibiotics. One resident received doxycycline for pneumonia and another received neomycin for UTI, but the IPN found no surveillance tracking forms or antibiotic reviews during therapy. The IPN stated the facility protocol required review using Loeb's and/or McGeer's criteria and monitoring for adverse reactions, and the DON confirmed the antibiotics should have been evaluated and tracked per policy.
Dusty air vents were found above the beds of two residents, including one resident with hemiplegia, hemiparesis, anxiety, and major depression and another resident with metabolic encephalopathy, anemia, and depression. Both residents were observed in their rooms with dusty vents overhead, and an MTA confirmed the vents were dirty and stated they should be cleaned at least monthly because they are connected to other residents' rooms.
Failure to notify the MD of changes in condition affected two residents. One resident with failure to thrive, depression, and DM refused multiple meds and meals, but the chart did not show MD notification for several days. Another resident with HF, CKD, and weakness developed itching of both hands and feet; staff were aware through CNA and nurse communication, but the chart lacked a change-in-condition evaluation and MD notification, and no treatment had been ordered.
Failure to Provide Communication Board for Resident With Language Barrier: A resident with metabolic encephalopathy, Afib, HTN, and moderately impaired cognition was dependent for multiple ADLs and communicated in a primary language other than English. Surveyors observed that no communication board was present in the room or at the bedside during repeated checks, and CNAs confirmed the resident did not have one. The DSS stated the board was only placed at the bedside after lunch on one day because it had not been there before, despite the facility policy requiring language access and accommodation of resident communication needs.
Delayed discharge planning for a resident with dysphagia, major depressive disorder, schizoaffective disorder, and impaired cognitive skills. The resident had a care plan for discharge to the community or ALF, but the SSD did not follow through on signed ALWP consent forms and transition paperwork, and the resident stated he repeatedly asked about discharge but was not told anything.
Failure to Offer Alternative Meal After Refused Lunch: A resident with dysphagia, depression, and schizoaffective disorder refused his lunch tray and remained hungry without being offered a substitute meal. CNA staff did not notify additional staff or provide alternatives, and the DTS confirmed dietary was unaware of the refusal, so no alternate tray was offered despite facility policy requiring a nourishing substitute when a meal is refused.
Staff failed to follow EBP and standard infection control practices for two residents. For one resident with a G-tube, CNAs entered the room without gowns during repositioning, one CNA left without hand hygiene after removing gloves, and an LVN did not change gloves between G-tube care tasks and used the same gloves while cleaning the flush syringe. For another resident on EBP for an indwelling catheter, multiple CNAs provided ADL care, shaving, dressing, and sponge bathing while wearing gloves but no gowns.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with a history of anxiety and injury was subjected to sexual abuse by another resident, who touched her inappropriately and exposed himself in the presence of both the resident and a CNA. The incident was witnessed and reported by staff, and both residents were documented as having the capacity to understand their actions. Facility policy requiring protection from abuse was not upheld, resulting in a violation of resident rights.
A sexual abuse incident occurred when a resident inappropriately touched and exposed himself to another resident in the presence of a CNA. Although the CNA promptly informed the CN, the required notifications to the SSA, Ombudsman, and local law enforcement were not made within the mandated two-hour timeframe, resulting in a delay of over two hours before authorities were contacted.
A resident's privacy was violated when another resident entered a common restroom without a lock or signage, leading to a breach of privacy and dignity. The facility's policies on resident rights and dignity were not followed, as confirmed by staff interviews.
A resident was prescribed Risperdal without a specific target behavior indicated in the order, contrary to the facility's policy on psychotropic medication use. The resident, diagnosed with schizophrenia and other mental health disorders, exhibited aggressive behavior, but the order lacked documentation for monitoring target behaviors or adverse reactions. Facility staff confirmed the omission, highlighting the need for specific behavior documentation to ensure medication appropriateness and effectiveness.
A facility failed to ensure a resident wore a prescribed brace for a right humerus fracture as ordered. The resident, with a displaced fracture and dementia, was observed without the brace, which was found on the nightstand. Staff interviews revealed confusion about reapplying the brace, with some expressing fear of moving the resident's arm. The importance of the brace for healing and immobilization was confirmed by the RN Supervisor and OT, while the DON emphasized the need for licensed staff to reapply it after baths.
Two residents with language barriers were not provided with communication aids, hindering their ability to communicate with staff. One resident with COPD and dementia did not have a communication board, while another with multiple diagnoses faced similar challenges. Staff were unable to effectively communicate with these residents, and the facility's policies on language access were not followed, posing potential risks in emergencies.
The facility failed to ensure sanitary conditions in food storage and dish sanitization. Food items in the kitchen were not properly labeled with received or expiration dates, and some were expired. Additionally, expired chlorine test strips were used to verify dishwasher sanitization, leading to unreliable results. These deficiencies posed potential health risks to residents.
Two residents with cognitive impairments were assisted with meals by a CNA who stood over them, failing to maintain eye level, which compromised their dignity. The facility's policy requires staff to be seated at eye level during feeding to ensure resident dignity and safety.
A resident with severe cognitive impairment was administered Quetiapine Fumarate for nine days without informed consent from their responsible party, violating their right to be informed and to consent to treatment. Facility staff confirmed the absence of consent in the resident's chart, contrary to policy requirements.
The facility failed to provide accessible call devices for three residents with limited mobility and cognitive impairments. One resident with limited hand motion struggled to use the call light, while two others had call lights placed out of reach. The facility's policy requires alternate communication means for residents unable to use standard call systems, but this was not implemented.
A facility failed to inform a resident of their right to formulate an advance directive, as required by policy. The resident, who had moderate cognitive skills and required assistance with daily activities, did not have a completed Advance Directives Acknowledgement form in their chart. This oversight was confirmed by an LVN and acknowledged by the Social Services Director, indicating a lapse in the facility's admission process.
Two residents in an LTC facility experienced deficiencies in their environment and equipment. One resident's room lacked a bulb in the overhead light, posing a fall risk, while another resident's wheelchair had holes and ripped edges, and the overhead light was inaccessible. Both residents have moderate cognitive impairment and require assistance with daily activities.
A resident with depressive disorder, presbyopia, and anxiety was found to have long and dirty fingernails, despite requiring assistance with personal hygiene. The resident had been requesting help with nail care but did not receive it. Facility staff acknowledged the issue, and the resident's care plan included grooming assistance, yet the facility failed to provide the necessary services.
A resident's room was found with an unattended open A&D ointment on the bedside table, posing a potential ingestion risk. The resident, with intact cognitive skills and no self-administration order, was observed in this condition. Staff confirmed the oversight, and the DON acknowledged the risk, highlighting a lapse in the facility's safety policies.
The facility failed to maintain accurate COVID-19 vaccination records for four staff members, including the IPN and DON, as required by policy. The Employee COVID-19 Vaccination log was not updated, which was confirmed during interviews and record reviews. This deficiency was noted as the facility's policy required maintaining a current tracking worksheet of staff vaccination status.
The facility failed to post accurate Daily Staffing Reports, with discrepancies noted on several dates between the reported and actual number of CNAs responsible for resident care. Interviews with the DSD and DON emphasized the importance of accurate staffing data to ensure compliance with NHPPD regulations and adequate staff coverage. The facility's policy requires daily posting of staffing data, but this was not consistently followed.
A facility failed to implement a resident-centered fall prevention plan for a high-risk resident with cognitive impairments and physical limitations. Despite identified fall risk factors, the care plan lacked specific interventions, focusing instead on post-fall measures. Staff interviews confirmed the need for supervision and assistance, highlighting the care plan's inadequacy in addressing the resident's needs.
A resident with severe cognitive impairment reported being hit by a male nurse, but the LTC facility failed to report the allegation to CDPH, the state ombudsman, and law enforcement as required by their policy. Despite staff awareness of the reporting requirements, the incident was not communicated to the necessary authorities, highlighting a deficiency in following the facility's abuse reporting procedures.
A resident with severe cognitive impairment alleged being hit by a male nurse, but the LTC facility failed to conduct a thorough investigation or report the findings to the State Survey Agency. Despite the report being made to staff, no interdisciplinary team meeting was held, and there was no documentation of an investigation into male staff members present at the time. This was contrary to the facility's abuse prevention and reporting policies.
A resident with a history of elopement and mental health issues left an LTC facility through a broken window without staff knowledge. Despite being identified as high risk for elopement, the resident's care plan interventions, including hourly head counts, were not effectively implemented. The facility's staff discovered the resident missing after a CNA returned from a lunch break, and the window was found inadequately secured. The resident remains missing.
The facility failed to provide adequate supervision to prevent a resident from eloping and did not ensure staff competency during a fire alarm. The resident, with severe cognitive impairments, exited through an unsupervised and unlocked gate during a fire alarm. Staff did not conduct required head counts or monitor exit doors properly, leading to the resident being found disoriented hours later by emergency services.
Inaccurate Fall Risk Documentation
Penalty
Summary
The facility failed to maintain accurate resident medical records for two sampled residents by documenting inaccurate Fall Risk Evaluations. For one resident, the record showed an admission history that included depression, atrial fibrillation, and schizoaffective disorder, with the MDS indicating severely impaired daily decision-making and extensive assistance needs for ADLs. The resident’s Fall Risk Evaluations dated 3/29/2026 and 5/24/2026 were documented the same, and staff stated the later assessment was copied from the earlier one even though the resident had a fall on 5/24/2026. During review and interview, staff identified that the resident’s fall-related assessment did not reflect the fall history and did not accurately capture gait/balance findings. The LVN stated the form should have shown a history of falls and that the resident had balance problems while standing and walking, but those items were not documented. The LVN also stated the medication section was inaccurate because the resident was taking multiple medications in the listed categories, including Ativan, Cymbalta, Lasix, and metoprolol, yet the form indicated only 1 to 2 such medications. For the second resident, the record showed diagnoses including seizure, osteoporosis with current fracture, and psychosis, with the MDS indicating modified independence for daily decision-making and assistance with multiple ADLs. The Fall Risk Evaluation dated 4/13/2026 documented a fall history, chairbound status, incontinence, and multiple gait/balance concerns, while the 4/21/2026 evaluation documented no fall history in the past 3 months, ambulatory status, and fewer predisposing conditions. Staff stated the 4/13/2026 form was inaccurate because the resident was ambulatory and not chairbound, and the 4/21/2026 form was inaccurate because it failed to reflect the recent fall, the resident’s multiple predisposing diseases, and the correct number of medications in the listed categories. Facility policy required accurate, objective, and complete documentation in the medical record.
Failure to Monitor a Wandering Resident’s Location
Penalty
Summary
The facility failed to monitor the whereabouts of a resident who wandered, according to the facility’s policy and the resident’s care plan. The resident had diagnoses of paranoid schizophrenia and major depressive disorder, and an elopement evaluation identified the resident as wandering and at risk for elopement. The care plan directed staff to monitor the resident’s location with visual checks every 2 hours, but the head count and call light check documentation for multiple shifts over several days was not signed, indicating the checks were not done. The incident involved another resident who was sleeping in a room when the wandering resident entered, took the resident’s radio, and began walking toward the door. The sleeping resident followed, grabbed the wandering resident’s shirt in the hallway, and the two residents struggled over the radio. During the struggle, both residents fell, and the wandering resident hit his head on the floor and on the metal frame of another resident’s bed. Staff interviews described hearing a commotion and finding both residents on the floor in the room. Staff interviews and record review showed the wandering resident had a history of going into other residents’ rooms and that the facility’s monitoring documentation was incomplete for several shifts. The DON stated the resident’s location or whereabouts was not monitored every 1 to 2 hours during the period reviewed, and that the head count and call light check was used to check residents’ locations, including those who wander. The facility’s policies on wandering, elopements, and resident supervision stated that unsafe wandering should be identified and that resident safety and supervision are facility-wide priorities.
Failure to Maintain Resident Dignity During Staff Interactions
Penalty
Summary
The facility failed to promote dignity and respect for three residents when staff used labels and informal terms instead of the residents’ names and, in one instance, assisted a resident with meals while standing over her. Resident 8 was admitted with hemiplegia, hemiparesis following a CVA, anxiety disorder, and major depressive disorder, and her MDS indicated intact cognitive skills for daily decision making but dependence in multiple ADLs. During observation, CNA 1 responded to Resident 8 using the term “my dear” when the resident asked about ice for her water and again when the resident asked for her fan to be turned on. CNA 1 later stated staff were not supposed to address residents using labels such as “my dear” and should use the names residents prefer to maintain dignity and respect. Resident 7 was admitted and re-admitted with diagnoses including ataxia, dementia, and dysphagia, and her MDS showed moderately impaired cognitive skills and dependence for eating and many other ADLs. During the dining observation, CNA 1 was first seated and then observed standing over Resident 7 while feeding her. CNA 1 later stated staff need to be at the resident’s eye level when assisting during meals to promote dignity and respect, and explained she remained standing because she could not adjust the chair height. CNA 1 also stated staff were not supposed to call residents who are dependent on staff for eating “feeders” because it does not promote respect and dignity. Resident 39 was admitted and re-admitted with diagnoses including metabolic encephalopathy, dysphagia, dementia, and history of falling, and her MDS indicated moderately impaired cognitive skills and dependence in several ADLs. During observations, staff referred to Resident 39 as “girl,” “sweetie,” and “Mama [NAME]” while interacting with her in her room and during meals. CNA 5 acknowledged that calling residents “sweetie” was not appropriate and stated residents should be addressed by their names to respect them, and CNA 4 stated it was not appropriate to call Resident 39 “Mama [NAME]” and that staff should address residents by their first or last names to maintain dignity.
Unsafe Room Conditions and Damaged Wheelchairs
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for three sampled residents when Resident 2’s room was observed with multiple used tissues scattered on the floor and splattered brownish stains on the wall. Resident 2 had been admitted with hydronephrosis with renal and ureteral calculous obstruction, cirrhosis of the liver, and pancytopenia, and his MDS showed moderately impaired cognitive skills for daily decision making and dependence for toileting hygiene, bathing, dressing, footwear, and transfers. During the observation, Resident 2 stated he dropped the tissues because he could not find the trash can, and staff observed that the wall remained stained. Housekeeping and nursing staff observed the same room conditions and stated the wall needed to be cleaned and trash removed from the floor. The housekeeper stated the stains might be from juice or coffee and that the wall needed cleaning to prevent bacteria growth and reduce the risk of illness. The CNA picked up the garbage can from the corner of the room and placed it near Resident 2’s bed after collecting the tissues, and the LVN stated the wall was dirty and housekeeping should clean it to maintain infection control. Resident 2 stated the housekeeper mopped the floor but did not clean the wall. The facility also failed to ensure two residents’ wheelchairs were in good condition. Resident 4, who had dementia, schizophrenia, and major depressive disorder and used a manual wheelchair, was observed sitting in a wheelchair with a cracked and torn left armrest exposing foam padding. The SSD confirmed the armrest was ripped and the foam was exposed, and Resident 4 stated, “I want a new wheelchair.” Resident 44, who had major depressive disorder, seizure, and muscle weakness and also used a manual wheelchair, stated the armrests were old, peeling, and rough on the skin. The SSD confirmed the armrest was peeling and stated it could cause discomfort, skin tears, and harbor bacteria; LVN 2 stated the facility did not follow its maintenance policy because the wheelchair armrest was not in good condition.
Failure to Provide Required Fingernail Grooming and ADL Assistance
Penalty
Summary
The facility failed to provide grooming services for two residents who required assistance with activities of daily living, specifically nail care, as identified in their care plans. One resident had a history that included lack of coordination, type 2 diabetes mellitus, and major depressive disorder, and was assessed as having moderately impaired cognitive skills and needing partial moderate assistance with eating, oral hygiene, bathing, and personal hygiene. The care plan directed staff to assist with ADLs as needed and to assist with grooming and trimming fingernails. During observation, this resident’s fingernails were noted to have visible food debris around the nail edges, yellowish-black discoloration underneath, and were chipped and jagged. A second resident with diagnoses including depression, schizoaffective disorder, and dementia was also assessed as having moderately impaired cognitive skills and needing partial moderate assistance with oral hygiene, bathing, and personal hygiene. The care plan likewise directed staff to assist with ADLs as needed and to assist with grooming and trimming fingernails. During observation, this resident’s fingernails were jagged with visible black residue underneath. The SSD and LVN stated both residents’ nails were dirty, jagged, and needed to be cleaned, trimmed, and smoothed, and the LVN stated the facility’s ADL support and fingernail care policies were not followed.
Unsafe environment and inadequate supervision for wandering residents
Penalty
Summary
The facility failed to provide a safe environment by leaving electrical cords improperly arranged in a resident’s room. Resident 44 was admitted with diagnoses including major depressive disorder, seizure disorder, and muscle weakness, and was assessed as cognitively intact but needing substantial to maximal assistance with several activities of daily living. During observation, multiple electrical cords were seen coiled around the metal base of the bed and lying loosely on the floor beneath it, creating a cluttered area. The Social Services Director stated that a white extension cord was wrapped around the metal bed frame with the bed plug and cellphone charger connected to it, and identified this as an accident hazard. Facility staff also acknowledged that extension cords are not supposed to be wrapped around the metal base of a resident’s bed. The facility also failed to implement interventions for Resident 6’s wandering behavior. Resident 6 had diagnoses including dementia, hyperlipidemia, and hypertension, and the MDS indicated severely impaired cognitive skills for daily decision making. Staff observed Resident 6 wandering in the hallway and entering another resident’s room, where the resident took a glass of soda from a bedside table and drank it. Staff stated that Resident 6 was not supposed to go into other residents’ rooms, but no specific care plan for wandering from room to room was found in the chart. Facility staff stated that Resident 6 was a wanderer and that residents are not supposed to enter other residents’ rooms for safety reasons. The facility also failed to adequately supervise Resident 28, who had dementia, Alzheimer’s disease, anxiety disorder, and severely impaired cognitive skills for daily decision making. The resident was repeatedly observed propelling a wheelchair into multiple residents’ rooms and entering rooms unsupervised, including while staff were present in nearby areas. Resident 28 entered one resident’s room during medication administration, entered another resident’s room multiple times, and was later observed in another resident’s room while no staff were present to intervene. Staff stated that Resident 28 needed to be redirected and supervised, that entering other residents’ rooms was not acceptable, and that the resident should have one-to-one supervision to prevent him from entering other residents’ rooms.
Failure to Monitor Residents on Anticoagulant Therapy for Bleeding
Penalty
Summary
The facility failed to monitor the use of anticoagulant therapy for two sampled residents, including monitoring for signs and symptoms of bleeding. One resident was receiving Heparin injections for DVT prophylaxis and had diagnoses including hydronephrosis with renal and ureteral calculous obstruction, cirrhosis of the liver, and pancytopenia. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making and dependence in multiple activities of daily living. During observation, multiple areas of discoloration were noted on both upper extremities, and the resident stated he was taking an anticoagulant and had bruises on his arms and legs. For this resident, the physician orders showed Heparin was administered over several days, but the MDS nurse stated there was no order for monitoring signs and symptoms of bleeding during that period. The nurse also stated the MAR did not contain documented evidence that the resident was monitored for bleeding, and the care plan did not include anticoagulant-related interventions. Facility staff stated that if a resident was started on anticoagulant therapy, a care plan should be in place right away to include monitoring for signs and symptoms of bleeding and side effects. The second resident had diagnoses including metabolic encephalopathy, Afib, and hypertension, and the MDS indicated moderately impaired cognitive skills and dependence in multiple areas of care. The physician order included Eliquis 2.5 mg twice daily for Afib. Although the resident had a care plan for anticoagulant therapy that directed staff to administer the medication, monitor for side effects and effectiveness every shift, and monitor for signs and symptoms of bleeding every shift, the MDS nurse stated there was no documented evidence in the MAR or nurses’ progress notes that this monitoring was performed. The facility’s anticoagulation clinical protocol stated staff and the physician would monitor for possible complications in individuals being anticoagulated, and the nurse would discuss excessive bruising, hematuria, hemoptysis, or other evidence of bleeding with the physician before the next scheduled dose.
Improper Glove Use During Food Preparation and Tray Line Assembly
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety and its Glove Use Policy during tray line assembly. During observation, Cook 1 wore disposable gloves while touching a kitchen facemask, then continued scooping food, used oven mittens over the same gloves to remove bread from the oven, touched serving plates, and removed foil from food trays without changing gloves. Cook 1 also wore the same gloves while touching a hairnet and later touched a blender and continued serving food without changing gloves. Cook 1 stated gloves should be changed when different utensils or tasks are involved and hands should be washed after removing gloves and between task changes. Kitchen Staff 1 and Kitchen Staff 2 were also observed wearing disposable gloves while touching a refrigerator handle and then handling food and serving plates without changing gloves or performing hand hygiene. Kitchen Staff 2 additionally touched the refrigerator handle, placed two glasses of chocolate milkshakes on a resident's tray, and pushed the serving tray cart to the dry storage room while still wearing the same gloves. During interviews, Kitchen Staff 1 and Kitchen Staff 2 stated they should have removed gloves and washed their hands when changing tasks or before using the serving/pushcart to prevent contamination. The Dietary Supervisor reviewed the facility's Glove Use Policy and the policy on preventing foodborne illness, which required glove changes before different tasks and handwashing after handling soiled equipment, during food preparation, and after activities that contaminate the hands.
Failure to Document Antibiotic Stewardship Reviews
Penalty
Summary
The facility failed to ensure antibiotic stewardship was completed for two residents who were receiving antibiotic therapy. Resident 20 was admitted with diagnoses including hypertensive heart disease with heart failure, chronic kidney disease, and generalized muscle weakness, and had moderately impaired cognitive skills with dependence for toileting, personal hygiene, bathing, dressing, and substantial assistance with eating and oral hygiene. Resident 20 received doxycycline hyclate 100 mg by mouth every 12 hours for pneumonia for five days, but the record contained no antibiotic surveillance tracking form or antibiotic review documenting evaluation during the course of treatment. Resident 2 was admitted with diagnoses including UTI, hydronephrosis with renal and ureteral calculous obstruction, and cirrhosis of the liver, and had moderately impaired cognitive skills with dependence for toileting hygiene, bathing, lower body dressing, and substantial assistance with personal and oral hygiene. Resident 2 received neomycin sulfate 500 mg by mouth twice daily for UTI for 10 days, and the record also contained no antibiotic surveillance tracking form or antibiotic review documenting evaluation during antibiotic administration. The Infection Preventionist stated that, per facility protocol, when antibiotics are ordered the IP nurse completes a Surveillance Data Collection Form to evaluate whether Loeb's criteria and/or McGeer's criteria are met and to monitor for adverse reactions or changes to stop antibiotic use. The IPN stated there were no antibiotic surveillance tracking forms or antibiotic reviews documented for either resident during antibiotic administration. The DON stated the antibiotic use for both residents should have been evaluated and tracked according to facility policy, and the facility policy required all clinical infections treated with antibiotics to undergo review and all antibiotic regimens to be documented on the facility-approved surveillance tracking form.
Dusty Air Vents in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and home-like environment for two sampled residents when air vents inside their rooms were found to be covered with dust. Resident 8 was admitted with diagnoses including hemiplegia, hemiparesis following a CVA, anxiety disorder, and major depressive disorder, and the MDS indicated the resident had intact cognitive skills for daily decision making but was dependent for toileting hygiene, bathing, dressing, footwear, and bed mobility. During an observation in the resident's room, the air vent directly above the bed was full of dust, and the resident stated, "The air vent on top of me is so filthy!" Maintenance Assistant 1 later confirmed the vent was dirty and stated it needed to be cleaned by moving the bed. Resident 20 was admitted with diagnoses including metabolic encephalopathy, anemia, and depression, and the MDS indicated moderately impaired cognitive skills for daily decision making with dependence in toileting hygiene, sit-to-stand, chair/bed transfers, and toilet transfers. During observation, the air vent above the resident's bed was dusty while the resident was lying in bed. Maintenance Assistant 1 also confirmed that Resident 20's air vent was dirty and stated the vents should be cleaned at least once a month because they are connected to other residents' rooms and residents can get sick. Facility policies reviewed included guidance for inspection of the heating and air-conditioning system, maintaining a clean and orderly homelike environment, and wet dusting horizontal surfaces regularly.
Failure to Notify MD of Resident Refusals and New Itching
Penalty
Summary
The facility failed to notify the MD of changes in condition for two sampled residents. One resident was admitted with adult failure to thrive, major depressive disorder, and type 2 DM, and had moderately impaired cognitive skills with dependence or assistance needed for multiple activities of daily living. Review of the MAR showed the resident refused 12 prescribed medications from 11/5/2025 through 11/12/2025 and refused 10 meals from 11/5/2025 through 11/12/2025. During interview and record review, the resident's chart did not show any MD notification for the refusals from 11/5/2025 through 11/10/2025. The DON stated the MD should have been notified so the plan of care and interventions could be coordinated. Another resident was admitted with hypertensive heart disease with heart failure, CKD, and generalized muscle weakness, and had moderately impaired cognitive skills with dependence or assistance needed for toileting, hygiene, bathing, dressing, and eating. On 1/6/2026, the resident told CNA 9 that both hands were itchy, and the CNA said he would inform the licensed nurse. The CNA later stated he informed LVN 5 about the itching, but LVN 5 said she was made aware only of dry skin and did not inform the doctor. On 1/8/2026, the resident reported that the itching had spread to both feet as well, and LVN 1 stated she had just become aware of the itching and there were no prescribed treatments for it. Record review and staff interviews showed the resident's chart did not document a change of condition evaluation or MD notification for the bilateral hand itching that began on 1/6/2026 or the bilateral foot itching that began on 1/8/2026. LVN 1 stated she did not notify the MD because she thought LVN 5 had done it, and the DON stated the MD should have been notified with documentation of the date and time, a revised care plan, and nursing monitoring for 72 hours according to facility policy.
Failure to Provide Communication Board for Resident With Language Barrier
Penalty
Summary
The facility failed to ensure that Resident 39, who had a language barrier, was provided a communication board in the resident’s primary language in accordance with facility policy. Resident 39 was admitted and later re-admitted with diagnoses including metabolic encephalopathy, atrial fibrillation, and hypertension. The MDS dated 10/31/2025 indicated the resident had moderately impaired cognitive skills for daily decision making and was dependent for multiple ADLs, including oral hygiene, toileting hygiene, bathing, dressing, footwear, personal hygiene, and transfers. During observation and interview, Resident 39 was seen in the room eating lunch and speaking in the resident’s primary language, while surveyor questions in English were answered in the primary language. On multiple observations, there was no communication board at the bedside or in the room. CNA 5 stated no communication board was provided, and CNA 4 stated the resident did not have one and that it would be useful to help the resident express needs and receive assistance promptly. The DSS stated the communication board was placed at the bedside only after lunch on 1/7/2026 because the resident had not had it before, and stated that providing the board was part of accommodating the resident’s needs under facility policy.
Delayed Discharge Planning for Resident with Cognitive and Psychiatric Diagnoses
Penalty
Summary
The facility failed to provide appropriate discharge planning for one sampled resident, Resident 45, who was admitted with dysphagia, major depressive disorder, schizoaffective disorder, and a public guardian. The admission record and quarterly MDS showed Resident 45 had moderately impaired cognitive skills for daily decision making and required varying levels of assistance with bathing, dressing, oral care, toileting, and personal hygiene, while remaining independent with eating. Resident 45’s discharge care plan, initiated on 6/2/2025, stated he was expected to discharge to the community, a board and care, or an assisted living facility, with the goal of discharge to the community. The care plan also stated the Social Services Director would intervene for appropriate and necessary follow-up as indicated. The IDT conference record dated 12/3/2025 documented a discharge plan to a lower level of care at an assisted living facility. During interview, Resident 45 stated he had repeatedly asked for discharge and said the facility was not telling him anything. The Social Services Director stated the resident had an expected discharge date the following month, but the facility needed to obtain waiver approval and switch the resident’s medical insurance. The SSD also stated the resident’s PG had signed an application, but she could not recall when. Record review showed signed Agency 1 consent forms dated 8/20/2025 authorizing transition care and placement on the ALWP waitlist, and the SSD stated she received those consents that same day but did not submit them for continued processing until they were found during review on 1/9/2026. The SSD stated that from 8/20/2025 to 1/9/2026, no submission of the signed consents had been made back to Agency 1 for Resident 45’s discharge planning.
Failure to Offer Alternative Meal After Refused Lunch
Penalty
Summary
The facility failed to ensure that an alternative meal was offered and provided to one sampled resident after his lunch tray was refused. Resident 45 was admitted with diagnoses including dysphagia, major depressive disorder, and schizoaffective disorder. His quarterly MDS indicated moderately impaired cognitive skills for daily decision making, and he was independent with eating. His care plan included a goal to maintain adequate nutritional status daily, and his order summary indicated a regular diet. During observation on 1/8/2026, Resident 45's lunch tray was seen uneaten at 12:39 PM, and he stated the food was terrible. CNA 7 said she would inform dietary staff of the refused lunch. At 1:16 PM, the tray was still uneaten, and Resident 45 stated he had not been offered a substitute meal but was hungry and wanted to eat. CNA 7 later stated she did not inform additional staff and did not offer alternative meal items. The Dietary Supervisor stated dietary staff was not aware of the refusal, so no alternative meal was offered, and confirmed that under facility policy, a resident who refuses a meal should be offered an alternative meal tray.
Failure to Follow EBP and Hand Hygiene Practices
Penalty
Summary
Standard infection prevention and control practices were not followed for two residents on the infection control care area. Resident 21 had diagnoses including epilepsy, dysphagia, and dementia, and the MDS indicated severe cognitive impairment and dependence for multiple activities of daily living. A physician order required Enhanced Barrier Precautions (EBP) related to G-tube use every shift. During observation, CNA 1 and CNA 8 entered Resident 21’s room wearing disposable gloves but no gown while repositioning the resident in a wheelchair. CNA 1 then removed her gloves and left the room without performing hand hygiene before entering another resident’s room. During the same resident’s medication administration, LVN 1 wore gown and gloves, touched the resident’s clothes, checked G-tube placement, and did not change gloves before administering medications via the G-tube. LVN 1 later washed and dried the resident’s flush syringe using the same disposable gloves and in a bathroom sink shared by two other residents. In interview, LVN 1 stated she should have changed gloves after checking G-tube placement and before administering medications, and should have removed gloves and used new ones before cleaning the flush syringe because dirty gloves could contaminate the clean syringe. CNA 1 stated the resident was on EBP and that gown and gloves should have been worn when transferring or pulling the resident up in the wheelchair, and hand hygiene should have been performed after removing gloves before entering another resident’s room. Resident 2 had diagnoses including hydronephrosis with renal and ureteral calculous obstruction, cirrhosis of the liver, and pancytopenia, and the MDS indicated moderate cognitive impairment and dependence for several ADLs. A physician order indicated EBP secondary to an indwelling catheter. During observation, CNA 1 assisted the resident with removing clothes, wiping the face, and sponge bathing while wearing disposable gloves but no gown. CNA 9 shaved the resident’s beard while wearing disposable gloves but no gown, and CNA 4 assisted the resident with dressing while wearing disposable gloves but no gown. In interview, CNA 4 stated they were supposed to wear gowns and gloves in the EBP room and had forgotten the gown while assisting with ADLs. CNA 1 stated they did not wear a gown while providing morning care and that gowns and gloves were supposed to be worn for residents on EBP because of infection control.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
A deficiency occurred when a resident was subjected to sexual abuse by another resident in the facility. The incident took place in the early morning hours when one resident, while waiting for medication at the nursing station, was approached by another resident in a wheelchair. The second resident touched the first resident inappropriately on the buttocks and subsequently exposed his genitalia to both the resident and a Certified Nursing Assistant (CNA) who was present at the scene. The CNA immediately confronted the perpetrator, informing him that such behavior was not allowed. The incident was witnessed by the CNA, who reported it to the Charge Nurse. Documentation and interviews confirm that the inappropriate touching and exposure were observed and that the events were communicated to facility leadership, including the Director of Nursing (DON) and Registered Nurse Supervisor (RN Sup 1). The victim provided a written statement detailing the sequence of events, including the physical contact and exposure, and described the emotional impact of the incident. The facility's records indicate that both residents involved had the mental capacity to understand and make decisions at the time of the incident. The facility's policy on abuse prevention, which states that residents have the right to be free from abuse by anyone, was not upheld in this instance. The failure to prevent the sexual abuse resulted in a violation of the resident's rights and had the potential to cause negative psychosocial outcomes. The report documents the sequence of events and the immediate actions taken by staff who witnessed the incident, but does not include any corrective or follow-up actions taken by the facility after the event.
Failure to Timely Report Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of sexual abuse involving two residents within the required two-hour timeframe to the State Survey Agency (SSA), Ombudsman, and local law enforcement. The incident occurred when one resident, while in a wheelchair, inappropriately touched another resident's buttocks and subsequently exposed his genitalia in the presence of the victim and a Certified Nurse Assistant (CNA). The CNA immediately informed the Charge Nurse (CN) of the incident, but the required notifications to authorities were not made until more than two hours after the event. Resident 1, who was the victim, had a medical history including an unspecified injury, open wound to the right knee, anxiety disorder, and effusion of the right ankle, and was determined to have the capacity to understand and make decisions. Resident 2, the perpetrator, had diagnoses of dysphagia, schizophrenia, acquired absence of the left leg above the knee, and anxiety disorder, and also had the capacity to make medical decisions. The incident was witnessed by CNA1, who reported it to the CN, but there was a delay in escalating the report to the appropriate authorities as required by facility policy and state regulations. Interviews with facility staff, including the Director of Nursing (DON), Registered Nurse Supervisor (RN Sup 1), Administrator, CN, and CNA1, confirmed that the incident was not reported within the mandated two-hour window. Facility policy clearly states that all allegations of abuse must be reported immediately, defined as within two hours, to the SSA, Ombudsman, and law enforcement. The delay in reporting was acknowledged by staff during interviews, and documentation confirmed that the notifications were made approximately two and a half hours after the incident occurred.
Privacy Violation in Restroom Use
Penalty
Summary
The facility failed to protect the privacy of a resident while using the restroom, which is a violation of the resident's rights to privacy and dignity. On 2/28/2025, Resident 1, who has schizoaffective disorder and requires substantial assistance with personal care, was using a common restroom when another resident, Resident 2, entered and asked Resident 1 to leave so they could take a shower. The restroom did not have a lock or signage to indicate it was in use, leading to the privacy breach. Interviews with staff, including a CNA, LVN, and the Director of Nursing, confirmed that the facility did not ensure the privacy and dignity of Resident 1. The facility's policies on resident rights and dignity emphasize the importance of protecting residents' privacy, but these were not adhered to in this instance. The lack of proper restroom facilities contributed to the violation of Resident 1's rights, as there was no way to signal that the restroom was occupied.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically Risperdal, as per the facility's policy and procedure on psychotropic medication use. The resident, who was admitted with diagnoses including schizophrenia, major depressive disorder, and anxiety disorder, was prescribed Risperdal without a specific target behavior indicated in the physician's order. This omission was identified during a review of the resident's records and confirmed through interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Interim Director of Nursing (DON). The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and the presence of mood symptoms, and the resident was observed to have received antipsychotic medication routinely. However, the order for Risperdal lacked documentation of a specific target behavior, such as sudden striking or hitting another resident, which was necessary to justify the medication's use. Additionally, there was no order to monitor or document the occurrence of target behaviors or any adverse reactions to the medication, which are critical components of ensuring the medication's appropriateness and effectiveness. Interviews with facility staff revealed that the resident had exhibited physically aggressive behavior, such as punching another resident, which was not documented in the Risperdal order. The staff acknowledged the importance of including specific target behaviors in medication orders to guide monitoring and assess the medication's effectiveness. The facility's policy requires that psychotropic medications be prescribed based on a comprehensive review of the resident's condition, including monitoring for adverse consequences, which was not adhered to in this case.
Failure to Ensure Resident Wore Prescribed Brace
Penalty
Summary
The facility failed to ensure that a resident wore a prescribed brace for a right humerus fracture as ordered by the physician and outlined in the care plan. The resident, who was admitted with a displaced fracture of the right humerus and dementia, was observed without the brace, which was found on the nightstand. The care plan and physician's orders specified that the brace should be worn at all times, except during sponge baths, to prevent dislocation and aid in healing. Interviews with staff revealed a lack of clarity and responsibility regarding the reapplication of the brace. A Restorative Nurse Assistant was unaware of when or why the brace was removed, while a Licensed Vocational Nurse expressed fear of moving the resident's fractured arm. The Registered Nurse Supervisor and Occupational Therapist confirmed the importance of the brace for immobilization and healing, and the Director of Nursing emphasized the need for licensed staff to reapply the brace after baths. The facility's policies on splinting and assistive devices were reviewed, highlighting the importance of maintaining range of motion and ensuring safety.
Failure to Provide Communication Aids for Residents with Language Barriers
Penalty
Summary
The facility failed to provide appropriate communication aids for residents with language barriers, which hindered their ability to communicate effectively with staff. Resident 24, who was admitted with chronic obstructive pulmonary disease and dementia, had a care plan indicating the need for communication devices due to a language barrier. However, during observations, it was noted that Resident 24 did not have a communication board at their bedside, and staff were unable to communicate with the resident effectively. Interviews with the Director of Nursing and a Registered Nurse confirmed that a communication board should have been available, but it was not found in the designated areas. Similarly, Resident 28, who had multiple diagnoses including polyneuropathies, COPD, and schizophrenia, also faced communication challenges due to a language barrier. The resident's preferred language was not accurately reflected in the admission records, and there was no communication board or aid available at the bedside. Observations showed that Resident 28 struggled to communicate with staff, leading to misunderstandings about the resident's needs. Staff confirmed the absence of communication aids and expressed difficulty in understanding the resident's requests. The facility's policies on translation and accommodation of needs were not adhered to, as staff were not adequately trained to provide language access services. The lack of communication aids and training posed a potential risk to residents in emergencies, as staff could not effectively communicate with residents who spoke different languages. The facility's failure to implement its policies resulted in residents being unable to communicate their needs, potentially delaying necessary care and treatment.
Deficiencies in Food Storage and Dish Sanitization
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage, preparation, and distribution of food, as observed during a survey. In the kitchen's produce refrigerator and dry storage area, food items were found without labels indicating the received or expiration dates. Some items, such as Parmesan cheese and ground pork, were past their use-by dates, and other items like cups filled with red liquid and milk lacked serve-by dates. The Dietary staff confirmed the absence of proper labeling and acknowledged the risk of residents consuming expired food, which could lead to illness. Additionally, the facility did not ensure the proper sanitization of dishware due to the use of expired chlorine test paper strips. The Dishwashing Staff and Dietary Staff Supervisor confirmed that the test strips used to verify the dishwasher's sanitization were expired, rendering the test results unreliable. This oversight could result in cross-contamination, as the dishwasher might not effectively sanitize the dishes. The facility's policies and procedures require all food to be labeled with dates and the dishwasher to be properly sanitized, but these were not adhered to, leading to potential health risks for the residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents during meal assistance. Resident 37, who was admitted with generalized muscle weakness and polyneuropathy, was observed being assisted with eating by a CNA who stood over the resident, not maintaining eye level, and used a towel as a clothing protector. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for partial assistance with eating. Similarly, Resident 42, diagnosed with major depressive disorder and dementia, was also assisted by the same CNA who stood over the resident while feeding. The MDS for Resident 42 showed severe cognitive impairment and a requirement for partial assistance with eating. Interviews with staff, including an LVN and the DON, confirmed that staff should be seated at eye level with residents during feeding to ensure dignity and safety, as per the facility's policy revised in July 2017.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility's licensed staff failed to obtain informed consent from the responsible party of a resident before administering Quetiapine Fumarate, an antipsychotic medication. This deficiency was identified during a survey involving observation, interviews, and record reviews. The resident in question was admitted with diagnoses including schizophrenia, anxiety, and dementia, and was noted to be severely impaired in cognitive skills for daily decision-making. Despite this, the resident was administered Quetiapine Fumarate for nine days without the necessary informed consent, violating the resident's right to be fully informed and to consent to receive psychoactive medications. The facility's policy and procedure documents, as well as federal and state laws, require that residents be informed of their medical condition and treatment options, and that informed consent be obtained prior to administering any medication or treatment. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that the informed consent was not present in the resident's chart, and that the medication was administered without authorization. This oversight highlights a failure to adhere to established protocols for informed consent, as outlined in the facility's policies.
Deficiency in Call Device Accessibility for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation to meet the needs of three residents, resulting in deficiencies related to the accessibility of call devices. Resident 37, who had limited range of motion in both hands due to generalized muscle weakness and polyneuropathy, was not provided with an appropriate call device. Despite being dependent on assistance for various daily activities, Resident 37's call light cord was placed on top of the bed, making it difficult for the resident to use. During an observation, the resident struggled to pull the call light cord and expressed frustration, indicating that he often resorted to yelling for help. A registered nurse confirmed that Resident 37 would not be able to pull the cord due to contracted hands and suggested that a touch-activated call light would be more suitable. Similarly, Resident 45, who had muscle wasting and metabolic encephalopathy, was observed with a call light mounted to the wall, with the cord wrapped around the base, approximately seven feet away from the resident. This placement rendered the call light inaccessible to Resident 45, who required partial assistance with daily activities. A registered nurse acknowledged that the resident would not be able to reach the call light in its current position. Resident 208, diagnosed with muscle wasting, atrophy, and lack of coordination, also faced issues with call light accessibility. The call light in Resident 208's room was attached to the wall, about seven feet away, with only a short metal string attached, making it impossible for the resident to reach. The resident confirmed the inability to reach the call light to request help. The facility's policy indicated that residents should be provided with a means to call staff for assistance, and if a disability prevents the use of the call system, an alternate means should be documented in the care plan. However, this was not adhered to for the residents in question.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to adhere to its policy regarding advance directives for one of the four sampled residents, identified as Resident 208. Upon review, it was found that the facility did not provide Resident 208 with written information about the option to formulate an advance directive. This oversight was confirmed during an interview with a Licensed Vocational Nurse (LVN 1), who acknowledged that the Advance Directives Acknowledgement form in Resident 208's chart was blank. The resident was admitted with diagnoses including muscle wasting, atrophy, and lack of coordination, and had moderate cognitive skills for daily decision-making, requiring varying levels of assistance with daily activities. The Social Services Director (SSD) stated that the facility's procedure is to complete the Advance Directives Acknowledgement form upon admission or as soon as possible, to ensure residents are aware of their rights to formulate an advance directive. However, in this case, the form was not completed, leaving Resident 208 uninformed of their rights and potentially impacting the staff's ability to carry out the resident's healthcare wishes in an emergency. This deficiency highlights a lapse in the facility's process for ensuring residents are informed about their healthcare rights and options.
Deficiencies in Resident Environment and Equipment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents, as required by its policy. Resident 45's room was observed to have an overhead light without a bulb, which could pose a risk for falls and injuries in the dark. The resident, who has moderate cognitive impairment and requires assistance with various daily activities, was at risk due to the lack of adequate lighting. Resident 208's wheelchair was found to have multiple holes and ripped edges on the seat, making it uncomfortable and potentially hazardous for the resident's skin. Additionally, the overhead light in Resident 208's room was not accessible due to a short metal string, preventing the resident from turning it on. This resident also has moderate cognitive impairment and requires substantial assistance with daily activities, including the use of a wheelchair. The facility's policies emphasize the importance of providing a safe, clean, and comfortable environment with adequate lighting to promote safety and independence. However, the observations and interviews revealed that these policies were not followed, leading to deficiencies in the care and environment provided to Residents 45 and 208.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who was unable to perform activities of daily living independently. Resident 8, who was admitted to the facility with diagnoses including depressive disorder, presbyopia, and anxiety, was observed to have long and dirty fingernails. Despite having the capacity to understand and make decisions, Resident 8 required substantial maximal assistance with personal hygiene. During observations and interviews, it was noted that the resident's fingernails were not trimmed and were dirty, with debris under the nails. The resident expressed that they had been requesting nail clippers for a long time but had not received assistance. The facility's staff, including LVN 3 and LVN 4, acknowledged the condition of the resident's fingernails and the importance of keeping them clean and trimmed to prevent potential harm and bacterial harboring. The resident's care plan indicated the need for assistance with grooming and fingernail trimming, yet this was not being followed. The Director of Nursing also emphasized the importance of maintaining good hygiene to prevent infection. The facility's policies and procedures stated that residents unable to carry out ADLs independently should receive necessary services to maintain grooming and hygiene, which was not adhered to in this case.
Failure to Maintain Accident-Free Environment
Penalty
Summary
The facility failed to maintain an accident-free environment for a resident by leaving an open A&D ointment on the resident's bedside table. This ointment, used as a moisturizer for skin irritations, was observed unattended in the resident's room. The resident, admitted with diagnoses including depressive disorder, presbyopia, and anxiety, was noted to have intact cognitive skills for daily decision-making and was independent with eating but required assistance with personal hygiene. Despite the resident's capacity to understand and make decisions, there was no order on the resident's chart indicating permission to self-administer medication. During observations and interviews, it was confirmed by a CNA and an LVN that the ointment was left unattended, which could pose a risk if ingested by wandering residents. The facility's Director of Nursing acknowledged that leaving open medication at the bedside was unacceptable, especially in a setting with residents who might have serious mental illnesses. The facility's policies emphasized maintaining a safe environment and preventing accidents, yet this incident demonstrated a lapse in adhering to these policies.
Failure to Maintain Accurate COVID-19 Vaccination Records for Staff
Penalty
Summary
The facility failed to maintain accurate documentation of COVID-19 vaccination status for four out of 73 staff members, as required by their policy. During an interview and record review, the Infection Prevention Nurse (IPN) confirmed that the Employee COVID-19 Vaccination log was not updated to reflect the vaccination status of herself, the Director of Staff Development, the Dietician, and one of the Activity Assistants. This oversight was acknowledged by the IPN, who stated that the log did not accurately list staff who had received the current COVID-19 vaccine. The Director of Nursing (DON) emphasized the importance of having an up-to-date vaccination log to identify staff at high risk of contracting COVID-19, especially those with co-morbidities. The DON also noted the necessity of accurate reporting to the National Healthcare Safety Network and the California Immunization Registry. The facility's policy required the IP to maintain a tracking worksheet of staff vaccination status, which was not adhered to, leading to the deficiency.
Inaccurate Daily Staffing Reports
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Daily Staffing Report, which is required to be posted daily in accordance with the facility's policy and procedure. On 11/11/2024, the Daily Staffing Report was not posted, and on multiple dates, including 11/8/2024, 11/11/2024, 11/12/2024, and 11/13/2024, the report did not accurately reflect the total number and actual hours of certified nursing assistants (CNAs) responsible for resident care. These discrepancies were identified through observation, interviews, and record reviews, revealing that the posted reports did not match the actual staffing levels as indicated by the Facility Staffing Assignment and Sign-In Sheets. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) highlighted the importance of accurate staffing reports to ensure adequate staff coverage and compliance with Nursing Hours Per Patient Day (NHPPD) regulations. The DSD acknowledged the inaccuracies and the potential impact on the quality of care if the facility had fewer CNAs than reported. The facility's policy, revised in August 2022, mandates that staffing data be posted within two hours of each shift's start, in a prominent location, and in a clear format. However, the facility failed to adhere to this policy, resulting in the potential for residents and visitors to be uninformed about the facility's staffing levels.
Failure to Implement Resident-Centered Fall Prevention Plan
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered fall care plan for a resident, identified as Resident 1, who was at high risk for falls. The resident was admitted with multiple diagnoses, including lack of coordination, muscle wasting, generalized muscle weakness, and dementia, which contributed to their fall risk. The Minimum Data Set (MDS) assessment indicated that the resident required substantial assistance with various activities, including walking, toileting, and dressing, due to severely impaired cognitive skills and fluctuating decision-making capacity. The facility's fall risk evaluation identified several risk factors for Resident 1, including disorientation, incontinence, orthostatic hypotension, predisposing diseases, multiple medications, balance problems, and decreased muscular coordination. Despite these identified risks, the care plan did not include specific interventions tailored to the resident's needs, such as supervision during ambulation and assistance with transfers. Interviews with facility staff, including the Director of Rehab, MDS Nurse, and Licensed Vocational Nurse, confirmed that the resident required supervision and assistance due to their unsteady gait and cognitive impairments. The facility's policy and procedure for managing falls and fall risks emphasized the need for resident-centered interventions to address specific risk factors. However, the care plan for Resident 1 primarily focused on post-fall interventions rather than preventive measures. The Director of Nursing acknowledged that the care plan was inadequate and did not align with the facility's policy, which required comprehensive, person-centered care plans with measurable objectives and timeframes to meet residents' needs.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the appropriate authorities, including the California Department of Public Health (CDPH), the state ombudsman, and local law enforcement. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses of encephalopathy and Alzheimer's disease, reported to a family representative that he was hit by a male nurse. Despite the report being made to the Director of Nursing (DON), the allegation was not communicated to the required external agencies as per the facility's policy. The resident's cognitive impairments, as documented in the Minimum Data Set, indicated severe impairment in decision-making and required substantial assistance with daily activities. The incident was initially reported by the resident's family representative to a Licensed Vocational Nurse (LVN), who then informed the DON. However, the DON acknowledged that the allegation was not reported to CDPH, the state ombudsman, or law enforcement, which is a requirement under the facility's policy for handling abuse allegations. Interviews with various staff members, including LVNs and a Certified Nursing Assistant (CNA), confirmed that the facility's policy mandates immediate reporting of abuse allegations to the relevant authorities within two hours. The facility's policy, titled 'Abuse Investigation and Reporting,' outlines the procedure for reporting such incidents, emphasizing the need for prompt communication with local, state, and federal agencies. Despite this, the facility did not adhere to its policy, resulting in a failure to report the abuse allegation involving the resident.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policy for abuse prevention and reporting in the case of a resident who alleged physical abuse by a male nurse. The resident, who was admitted with diagnoses of encephalopathy and Alzheimer's disease, reported to his family representative that he was hit by a male nurse. Despite the resident's severe cognitive impairment and fluctuating capacity to understand and make decisions, the facility did not conduct a thorough investigation into the allegation. Interviews with the Director of Nursing (DON), Licensed Vocational Nurse (LVN), and Certified Nursing Assistant (CNA) revealed that the allegation was reported to the facility staff, but no interdisciplinary team meeting was conducted to address the incident. The DON admitted that there was no documentation or investigation into the male staff members working on the day of the alleged incident. The facility's policy required such incidents to be promptly reported and thoroughly investigated, but this was not followed. Additionally, the facility failed to provide a written report of the investigation findings to the State Survey Agency within the required five working days. The Administrator acknowledged that an investigative report was not completed, and there was no documentation indicating that the facility had investigated the possible involvement of male staff members. This lack of action and documentation was contrary to the facility's policies and procedures for abuse prevention and reporting.
Resident Elopement Due to Inadequate Supervision and Facility Security
Penalty
Summary
The facility failed to adequately supervise and ensure the safety of a resident who was at high risk for elopement. The resident, who had a history of elopement and was diagnosed with encephalopathy and schizoaffective disorder, bipolar type, left the facility through a broken window without staff knowledge. The resident's care plan indicated a high risk for elopement, requiring hourly head counts and frequent visual checks, but these measures were not effectively implemented. On the day of the incident, the resident was last seen by a CNA at 11:00 AM in their room. The CNA went on a lunch break, and upon returning at 12:10 PM, discovered the resident missing and the window broken. The facility's staff, including an LVN and the DON, conducted a search within the facility and the surrounding area but were unable to locate the resident. The window in the resident's room was found to be inadequately secured, with a gap at the top, which may have facilitated the resident's escape. Interviews with facility staff revealed that the standard procedure of hourly head counts was not sufficient for this high-risk resident, as acknowledged by the DON. The facility's policies on emergency procedures for missing residents and elopement risk management were not effectively followed, contributing to the resident's unsupervised departure. As of the last update, the resident had not been found.
Failure to Prevent Resident Elopement and Ensure Staff Competency During Fire Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as low risk for elopement. On the day of the incident, the facility exit doors were not supervised, and a gate was left open, allowing the resident to elope. The resident, who had severe cognitive impairments and a history of dementia, schizoaffective disorder, and epilepsy, was found wandering and disoriented several hours later by emergency services. The facility's head count and call light check logs were incomplete, and staff failed to report the resident missing promptly. The incident was exacerbated by a fire alarm that was pulled by another resident, causing the exit doors to unlock temporarily. During this time, the Maintenance Supervisor left the gate open while retrieving a key to reset the alarm. Surveillance footage confirmed that the resident exited the facility through the back door and gate during this period. Interviews with staff revealed that routine checks and head counts were not conducted as required, and there was a lack of immediate action to account for all residents when the fire alarm was activated. Additionally, the facility failed to ensure that staff, specifically a Certified Nursing Assistant, had the necessary competency to manage residents during a fire alarm. Despite receiving in-service training on elopement prevention and safety, the CNA did not follow proper procedures during the fire alarm, contributing to the resident's elopement. The Director of Nursing acknowledged that staff should have been monitoring exit doors and conducting head counts more diligently, as per the facility's policies and procedures.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Gabriel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Center | 0.6 mi | ★★★★★ | 8 | 0 |
| Huntington Drive Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 38 | 0 |
| Baldwin Gardens Nursing Center | 1.7 mi | ★★★★★ | 16 | 0 |
| Pine Grove Healthcare & Wellness Centre, Lp | 1.7 mi | ★★★★★ | 18 | 0 |
| Santa Anita Convalescent Hospital | 1.8 mi | ★★★★★ | 17 | 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.