Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Santa Clarita Post-acute Care Center during CMS and state inspections, most recent first.
A resident with intact cognition and assistance needs for ADLs reported that a receptionist spoke to him in a loud manner in the activity room, telling him to grow up and not act like a child after he complained about an air conditioner being moved. Another resident witnessed the exchange and said the receptionist raised her voice unnecessarily and was rude to residents. The DON stated the receptionist was trying to calm the resident, but the resident felt verbally abused.
Call lights not kept within reach for multiple residents. A resident with moderate cognitive impairment and dependence for several ADLs, a resident with severe dementia and fall risk, a resident with severe cognitive impairment, a resident with multiple mobility-limiting diagnoses, and a cognitively intact resident needing extensive ADL assistance all had call lights placed out of immediate reach during observation. Staff and the DON stated the call lights were not accessible and that residents would not have been able to summon help when needed.
A resident with dementia and significant care needs had an open packet of A&D ointment left on the bedside table without a documented self-administration assessment, order, or care plan, and the DON and MDSC stated the facility's self-administration policy was not followed. In a separate room, staff observed a puddle of water at the foot of another resident's bed; CNA and DON statements confirmed that wet floors are an environmental hazard and should be removed or secured immediately.
Infection Control Failures During Catheter Care and Medication Administration: A resident with an indwelling Foley catheter was observed with the catheter tubing and bag on the floor, contrary to the facility’s catheter care policy, and the CNA, MDSC, and DON all acknowledged the practice was not followed. In a separate event, an RN allowed a resident with impaired cognition to handle oral meds with a saliva-moistened finger and ingest the contaminated pills without intervention, which the DON stated was not consistent with policy or infection control principles.
A resident with a cervical fracture, anxiety, unsteadiness, and muscle weakness was transported in a shower chair with a sheet that did not fully cover the body, leaving the buttocks visible to others in the hallway. The MRA observed the exposure, CNA acknowledged the resident was not fully covered, and the DON confirmed the facility’s privacy policy was not followed during transport to the shower.
A resident with a left BKA, DM, ESRD, and HD dependence alleged that a CNA was rough with him and tried to push him out of bed while he was on a bedpan and calling for help. The CNA said the resident accused her of trying to push him out of the bed, but the allegation was not reported immediately to CDPH, the ombudsman, or law enforcement as required by facility policy and state law, and the DON and ADM stated the abuse protocol was not followed.
Failure to Report and Investigate Abuse Allegation: A resident with L BKA, DM, ESRD, and HD dependence alleged that a CNA was rough with him and tried to push him out of bed after leaving him on a bedpan and delaying response to the call light. The CNA said the resident accused her of trying to push him out of the bed and she completed a SWT, but the DON and ADM stated the abuse allegation was not reported or thoroughly investigated per facility P&P, and required notifications and documentation were not completed.
Missing PASARR Level II Care Plan: A resident with MS, functional quadriplegia, schizophrenia, depression, and muscle wasting/atrophy had a positive PASARR Level II determination, but the record showed no care plan specific to the Level II recommendations. The MDSC and DON stated the resident needed a personalized plan to address social, behavioral, and emotional support needs, and the facility policy required PASARR screening and referral for Level II when indicated.
Failure to Resubmit PASARR Screening After Case Closure: A resident with psychosis and dementia had a positive PASARR Level I screen for SMI and required a Level II MH evaluation. The evaluator could not complete the process after repeated unsuccessful attempts to contact the facility, the case was closed, and the required new Level I screen was not resubmitted by an LN with PASARR access. The MDSC and DON stated the facility did not follow its PASARR process.
A resident with COPD and chronic respiratory failure had a care plan that listed continuous O2 at 2 LPM even though the physician ordered 4 LPM via NC, and staff observed the resident receiving 2 LPM. Another resident’s care plan listed Farsi as the language spoken even though the MDS, family member, and CNA identified Arabic as the resident’s language. RN, MDSC, and DON all acknowledged the care plans did not match the resident-specific information.
Unlabeled Urinal Bottle in Resident Room: A resident with bladder incontinence had a urinal bottle in the room that was not labeled with the resident’s name. An RN stated urinals should be labeled for infection control and to prevent them from being mixed up with other residents’ urinals, and a CNA, MDSC, and DON all confirmed that unlabeled urinals can be misplaced or used by other residents and may lead to infection such as UTI or skin infection.
Incorrect Labeling of Water Flush Bag for Resident with Feeding Tube: A resident with a feeding tube had a flush bag of clear liquid labeled as Diabetisource instead of water. The resident had hemiplegia, hemiparesis, generalized weakness, and was dependent with ADLs; the LVN stated the label should include the rate, time, and date and must identify water, and the DON confirmed the bag was mislabeled.
A facility failed to provide respiratory care per physician orders and policy for two residents receiving O2 therapy. One resident with COPD and chronic respiratory failure was observed on O2 at 2 LPM via NC despite an order for continuous O2 at 4 LPM, and nursing staff confirmed the concentrator was set incorrectly. Another resident with acute respiratory failure and other lung conditions received O2 at 2 LPM via NC without an active order to continue therapy and without documented monitoring while O2 was in use; the DON and nursing staff stated O2 requires an active physician order and monitoring.
Unclean Food Scooper Observed in Kitchen: Surveyors observed one of two food scoopers used for dry goods with a white residue on it during a kitchen observation with the DS. The DS stated the scooper must be cleaned after each use to prevent contamination risk to residents, and the facility P&P titled "Sanitation" indicated utensils shall be kept clean.
A resident with multiple serious diagnoses, including CHF, atrial fibrillation, acute respiratory failure with hypoxia, and a DNR order, had a progress note stating vital signs were assessed and within normal limits during the night shift, but the RN did not document the numeric values for HR, RR, BP, Temp, or O2 sat. The MDSC, RN, and DON all confirmed the values should have been recorded, and the facility’s P&P required complete, objective, and accurate documentation in the medical record.
A resident with sepsis, muscle weakness, unsteadiness of feet, and UTI was found with a nonfunctional call light while lying in bed and reporting that she had been calling for help all morning and needed to be changed. The call light cord was severed and not connected to the wall, the door indicator did not light up when pressed, and staff who entered the room did not identify the problem until later. The MDSC and DON stated the call light should always be functioning and within reach, and the DON said facility policy was not followed.
Staff failed to verify the internal temperature of grilled chicken used as a substitute entrée for several residents who avoided pork, despite a facility policy requiring Food and Nutrition Services staff to take food temperatures on the tray line before service. On the observed lunch meal, a cook checked temperatures of other foods but plated and distributed grilled chicken, and later pureed a portion for a diet-changed resident, without taking its temperature. Multiple residents with conditions such as Alzheimer’s disease, dysphagia, DM, COPD, CKD, and cancer, and with documented pork dislikes or specific diet textures, were affected by this practice, while the Dietary Supervisor and DON both confirmed that required temperature checks were not performed as outlined in the meal service policy.
Licensed nurses did not monitor or document the medical status of two residents after changes of condition, including one with diabetes, anemia, and COPD, and another with gastrointestinal issues. One resident also received oxygen therapy at a rate higher than the physician's order. The DON confirmed that required monitoring and documentation were not completed according to facility policy.
Staff failed to follow COVID-19 infection control protocols when a CNA removed and disposed of PPE, including an N95 mask, inside a COVID-19 isolation room, and an LVN did not wear an N95 mask properly or perform hand hygiene after touching the mask and using shared equipment. These actions were not in accordance with facility policies requiring proper use of N95 respirators and hand hygiene during a respiratory outbreak.
A resident with severe cognitive impairment and high fall risk, who required the call light to be within reach per their care plan, was found with the call light rolled up and out of reach. The DON confirmed the call light was not accessible, contrary to facility policy and the resident's care plan.
A resident with diabetes, depression, and epilepsy was served a meal containing fish despite a physician order and documented preference for no fish. The resident's care plan did not include this dietary preference, and staff were unaware until notified by a family member. The nutrition care plan was not individualized as required by facility policy.
A resident with hypotension and heart failure did not receive their midodrine HCl 10 mg tablet as prescribed, and a midodrine pill was found on the hallway floor. The LVN believed the medication was given but failed to document it correctly and did not ensure the resident swallowed the pill, contrary to facility policy requiring timely administration and documentation.
A resident with multiple medical conditions and a physician order for a no fish diet was served fish after their dietary preference was not communicated to the dietary department or documented on the Diet Communication Form. Staff were unaware of the restriction, and the meal ticket did not reflect the resident's preference, resulting in the resident receiving a meal that did not accommodate their documented dietary needs.
A resident with multiple medical and psychiatric diagnoses reported to an LVN that another resident touched his legs, making him feel scared and uncomfortable due to wounds in the area. The LVN relayed the concern to the SSA, but the SSA did not follow up with the resident or document the complaint, resulting in a failure to investigate and record the grievance as required by facility policy.
A resident with multiple chronic conditions, who was dependent on staff for care, repeatedly refused to have her incontinence brief checked by a CNA. Despite the resident's clear verbal refusals, the CNA continued to attempt care, pulling the blanket and proceeding until another CNA intervened. Staff interviews and facility policy confirmed that the resident's right to refuse care was not honored, resulting in a violation of her rights to dignity and self-determination.
Two residents in an RNA feeding program were assisted with eating in a rehab therapy room instead of a homelike setting, contrary to facility policy. Additionally, a resident with a tibia fracture had an unclean and damaged floor mat, which was not addressed by housekeeping or staff. These deficiencies were identified through observations and interviews, highlighting the facility's failure to maintain a homelike environment.
The facility improperly used physical restraints on four residents without obtaining necessary physician orders, informed consent, or developing care plans. Beds were placed against walls and wedge pillows were used under fitted sheets, restricting residents' movement without proper documentation or consent.
A facility failed to implement comprehensive care plans for four residents, leading to deficiencies in medication management. One resident lacked a care plan for methenamine hippurate, risking antibiotic resistance. Two residents did not receive non-pharmacological interventions for trazodone and Haldol, as outlined in their care plans. Another resident's care plan lacked measurable goals for sleep monitoring with trazodone, preventing assessment of medication effectiveness.
Two residents in the facility did not receive insulin injections with proper site rotation, as required by physician's orders and professional standards. This failure was identified through record reviews and staff interviews, revealing repeated use of the same injection sites, which could lead to complications such as bruising and lipodystrophy.
The facility failed to limit the use of psychotropic medications for several residents, neglecting to set stop dates or durations for lorazepam and Ativan, and did not implement non-pharmacological interventions for residents using trazodone and Haldol. Additionally, the facility did not monitor the effectiveness of these medications by tracking symptoms or sleep patterns, potentially leading to unnecessary medication use.
A facility failed to maintain a medication error rate below five percent, resulting in a 6.9% error rate due to two errors affecting a resident. Medications were administered outside the prescribed timeframe, contrary to facility policy, leading to a medication error as defined by the facility's guidelines.
Two residents in the facility experienced significant medication errors due to the failure to rotate insulin injection sites as per physician's orders and manufacturer's guidelines. This non-compliance with established protocols led to repeated insulin administration in the same areas, increasing the risk of complications such as bruising and lipodystrophy.
The facility failed to ensure safe food storage and preparation practices, as observed during a survey. Food items in the walk-in refrigerator were not labeled according to policy, posing a risk of serving expired or allergenic foods. Additionally, used towels were improperly stored on a meat slicer, risking cross-contamination. The walk-in freezer also showed signs of improper temperature maintenance, with ice build-up indicating potential thawing and refreezing of stored meat.
The facility failed to properly dispose of garbage and refuse, with trash bags left outside dumpsters, potentially attracting pests and spreading infection. Staff acknowledged the importance of proper disposal, and the facility's policy requires waste to be stored in a manner inaccessible to pests.
A facility failed to maintain a resident's dignity by not providing a privacy cover for their urinary drainage bag. The resident, who required assistance with daily activities and had an indwelling catheter, was observed with an uncovered drainage bag. Both the Quality Assurance Nurse and the DON confirmed the absence of the cover, acknowledging it as a dignity issue. Facility policy mandates covering urinary catheter bags to promote resident dignity.
A resident with impaired cognition and high fall risk had their call light placed out of reach, contrary to their care plan and facility policy. The RN and DON confirmed the oversight, which could delay care. The facility's policy requires call lights to be accessible to residents at all times.
The facility failed to maintain privacy during medication administration for two residents, as privacy curtains were left open, potentially exposing their treatment to unauthorized individuals. Both residents had significant medical histories, and the LVNs involved acknowledged the oversight. The DON emphasized the importance of maintaining privacy, as outlined in the facility's policies.
A resident with significant weight loss and multiple health issues did not have their care plan updated to include a prescribed nutritional intervention, LiquaCel, despite a recommendation and order for its administration. The oversight was acknowledged by the DON, who noted the importance of updating care plans to reflect current interventions.
A resident with a stage 4 sacral ulcer did not receive consistent care as per their care plan, which required turning every two hours. Staff failed to document the resident's position and refusals to turn, and improper equipment was used, potentially worsening the resident's condition. Interviews confirmed lapses in care and documentation.
The facility failed to ensure a safe environment for a resident by improperly placing fall mats, leading to potential injury risks. Additionally, the facility did not accurately complete a fall risk assessment or conduct necessary IDT meetings for another resident after fall incidents, failing to adhere to protocols for resident safety.
A facility failed to provide proper care for a resident with a urinary catheter, leading to a potential risk of UTI. The resident's catheter tubing had a loop, preventing urine from flowing freely, which was confirmed by the QAN. The DON stated that catheter tubing should be free of loops to prevent urine backup. This failure violated the facility's policy on catheter care.
A facility failed to properly label a water flush bag for a resident with a feeding tube, leading to potential risks of over or under hydration. The resident, with severe cognitive impairment and other medical conditions, had a water flush bag labeled only with the date and time, missing critical information such as the resident's name, room number, and infusion rate. This oversight was confirmed by staff and did not comply with the facility's policy, posing a risk of nutritional imbalance and infection.
The facility failed to provide proper respiratory care for two residents. A resident's suction canister was not labeled with the date it was last changed, and another resident's oxygen tubing was found unlabeled and touching the floor. Additionally, the nebulizer mask and tubing were not stored correctly. These practices deviate from the facility's policy, which requires labeling and changing of equipment every seven days to prevent infection.
The facility failed to reconcile a medication emergency kit containing controlled substances at every shift change and did not include verifying signatures on accountability logs for controlled substances awaiting disposal. This lack of adherence to policies increased the risk of medication diversion and accidental exposure.
A facility failed to ensure a licensed pharmacist provided a recommendation on the use of methenamine hippurate as a prophylaxis for UTI for a resident. The resident had been on the medication since September 2023 without monitoring for signs and symptoms of UTI. The facility did not conduct necessary monitoring or follow up with the attending physician regarding the prolonged use of the medication, despite having a policy on Antibiotic Stewardship.
A resident was prescribed methenamine hippurate for UTI prophylaxis without adequate monitoring for signs and symptoms of UTI, leading to its prolonged use without an end date. The facility's staff did not follow the antibiotic stewardship policy, and there was a lack of communication with the physician regarding the medication's continued use.
A resident receiving hospice care did not receive the scheduled hospice aide visits as per the hospice plan of care. The resident, with conditions including malignant neoplasm of the colon and respiratory failure, was supposed to have hospice aide visits twice a week. However, during a specific week, only one visit occurred, with no documentation explaining the missed visit. This inconsistency was acknowledged by the facility's DON, who noted the potential impact on the resident's care choices and well-being.
A facility failed to maintain an effective infection control program by not labeling a resident's urinal, risking cross-contamination, and improperly storing clean linens on the floor, potentially leading to contamination. Staff acknowledged these lapses, which violate the facility's infection control policies.
A resident with a history of hip dislocation and severe cognitive impairment experienced severe pain and possible hip displacement, leading to hospital discharge. The facility failed to report the incident to the State Survey Agency within the required timeframe, as per their abuse reporting policy.
The facility failed to make the most recent survey results accessible to residents and their representatives by not posting them in a prominent location. The survey results were removed due to wall painting, and a sign indicated they were available upon request. Interviews with residents and staff confirmed the deficiency, and the facility's policy required the results to be maintained in an area frequented by residents.
Failure to Treat a Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat one resident with dignity and respect when a receptionist spoke to him in a loud manner and told him to grow up and not act like a child in the activity room. The resident, who was admitted with diagnoses including aftercare following surgical amputation, acquired absence of the left leg below the knee, type 2 DM, and anemia, had intact cognition and required assistance with bathing, lower body dressing, footwear, and set-up assistance with eating. He reported that the interaction occurred while he was in the activity room playing poker with other residents and became upset after a family member of another resident moved the air conditioner. The resident stated he felt disrespected and not treated with dignity, and another resident who witnessed the event said the receptionist raised her voice unnecessarily and should not have spoken to him in that manner. That resident also stated she feared the receptionist and described her as rude to residents. The DON stated the receptionist was trying to calm the resident but that the resident felt verbally abused, and the receptionist was suspended pending investigation. The facility policy stated residents are to be treated with dignity and respect at all times and staff are to speak respectfully to residents at all times.
Call lights not kept within residents' reach
Penalty
Summary
The facility failed to keep call lights within reach for five sampled residents: Residents 39, 44, 81, 73, and 117. The deficiency was identified through observation, interview, and record review under the environment facility task. The facility policy titled, Call Light, stated that call lights must be accessible to residents when in bed, from the toilet, from the shower or bathing facility, and from the floor. Resident 39 was admitted with diagnoses including dysphagia, spinal stenosis, anxiety disorder, and muscle weakness. The H&P indicated the resident had capacity to make needs known but could not make medical decisions, and the MDS showed moderate cognitive impairment with substantial to maximal assistance needed for eating and personal hygiene and dependence on staff for toileting, bathing, and transferring. The care plan directed staff to encourage use of the call light, but during observation the call light was found by the resident's right side near the shoulder and was not accessible. The LVN stated it should have been closer to the resident and was not accessible. Resident 44 had diagnoses including Alzheimer's disease, dementia, and contracture, and the H&P stated the resident did not have capacity to make medical decisions. The MDS showed severe cognitive impairment and dependence on staff for mobility and ADLs. The resident was also identified as being at risk for falls. During observation, the call light was clipped under the pillow on the left side of the resident's head, and the CNA stated the resident would not have been able to call for help because the call light was under the pillow and the resident had a splint on the left hand. Resident 81 had diagnoses including metabolic encephalopathy, schizophrenia, and depression, with severe cognitive impairment and dependence or partial/moderate assistance for mobility and ADLs. The call light was observed on the floor under the bed, and the CNA stated the resident would not have been able to call for assistance. Resident 117 had diagnoses including traumatic subdural hemorrhage, muscle weakness, unsteadiness on feet, fractures of the left femur and left knee area, anemia, dementia with behavioral disturbance, epilepsy, hypertension, GERD, and osteoarthritis. The call light was observed hanging on the bedside and not within immediate reach, and the CNA stated the resident would be unable to call for assistance when needed. Resident 73 had diagnoses including generalized muscle weakness, unsteadiness on feet, COPD, asthma, dysphagia, obesity, hypertension, lumbar spondylosis with radiculopathy, abdominal wall cellulitis, and status post artificial joint replacement. The MDS indicated the resident was cognitively intact, able to communicate needs, and required staff assistance with transfers, toileting hygiene, bathing, dressing, mobility, and other ADLs. During observation, the call light was hanging on the bedside and was not within immediate reach. The DON stated that call lights should always be within reach and acknowledged that the policy was not followed when residents could not access the call light.
Unsafe bedside medication and wet floor hazards
Penalty
Summary
The facility failed to ensure the resident environment was free of accident hazards for two sampled residents. For one resident, the record showed diagnoses including Alzheimer's disease and dementia, and the resident required maximal assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. During a concurrent observation and interview, an open packet of A&D ointment was found on the resident's bedside table. CNA 1 stated the ointment should not have been left at the bedside because it posed an infection control risk and a confused resident might grab it. The MDSC stated licensed staff are required to assess residents for the ability to self-medicate and that there must be a physician's order, a self-administration assessment, and a care plan before a resident self-administers medications. The MDSC stated there was no order, assessment, or care plan for this resident to self-administer A&D ointment, and that the ointment was not supposed to be at the bedside because it was unknown how long it had been open. The MDSC and DON both stated the facility's Self-Administration of Medications policy was not followed. For a second resident, the record showed diagnoses affecting mobility, balance, strength, cardiovascular status, and safety awareness. During a concurrent observation and interview, a puddle of water was observed on the floor at the foot of the resident's bed. CNA 3 stated someone could slip and fall and that the puddle created a potential environmental hazard. The DON stated water on the floor is an environmental hazard that should be removed immediately or the area secured until cleaned, and acknowledged that maintaining a safe environment free from accident hazards is the facility's responsibility.
Infection Control Failures During Catheter Care and Medication Administration
Penalty
Summary
Resident 93, who had diagnoses including Alzheimer’s disease, unspecified dementia with behavioral disturbances, and neuromuscular dysfunction of the bladder, had an indwelling Foley catheter. The resident’s H&P dated 2/2/26 indicated the resident was able to make medical decisions, and the MDS dated 4/22/2026 indicated the resident could make self-understood and understand others, had intact cognitive function, and required dependent to maximal assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. During a concurrent observation and interview on 6/1/2026, the Foley catheter bag and tubing were observed on the floor in the resident’s room. The CNA stated the bag and tubing should not be placed on the floor due to infection control concerns. During interview, the MDSC stated the Foley catheter should be positioned at the lowest part of the bladder and that the tubing and draining bag are not supposed to be on the floor because the floor is dirty and high risk for bacteria that can lead to possible UTI. The MDSC stated the facility’s policy and procedure titled Catheter Care, Urinary was not followed. The DON also stated that placing the Foley catheter tubing and draining bag on the floor creates a risk for the resident to get an infection such as UTI and acknowledged that the policy titled Catheter Care, Urinary was not followed. Resident 14 was admitted with diagnoses including anorexia, osteoarthritis of the right hip, hypothyroidism, schizophrenia, depression, anxiety disorder, and benign prostatic hyperplasia. The resident’s MDS indicated moderately impaired cognition with poor decisions and need for cues and supervision, along with deficits in temporal orientation and memory recall, and the resident required supervision to partial/moderate assistance with multiple ADLs and used a walker. During observation, RN1 administered medications while the resident placed the pills on the bedside table and picked them up one at a time using a saliva-moistened index finger before placing each pill into the mouth. RN1 observed this and allowed it to continue without intervention, and then stated the resident had been doing this all the time. The DON stated medications should be administered in a manner that maintains integrity and prevents contamination, and that when a resident handles medications with a saliva-contaminated finger, the nurse should intervene and replace contaminated medications as appropriate; the DON stated the observed practice was not consistent with facility policy or accepted infection control principles.
Resident Exposed During Transport to Shower
Penalty
Summary
The facility failed to honor one resident’s right to be treated with dignity and respect for personal privacy when Resident 39 was transported down the hallway to the shower room with the buttocks exposed to other residents, staff, and visitors. Resident 39 was admitted with diagnoses including a nondisplaced fracture of the second cervical vertebra, anxiety disorder, unsteadiness on feet, and muscle weakness. The resident’s H&P indicated the resident had the capacity to make needs known but could not make medical decisions, and the MDS showed the resident could understand others and make herself understood, but was dependent on staff for toileting, bathing, lower body dressing, and shower transfers. The resident’s care plan included an intervention to provide privacy during care. During a concurrent observation and interview, the Medical Records Assistant observed Resident 39 being pushed in a shower chair with a sheet that did not fully cover the body and left the buttocks visible, and stated the resident should be fully covered while being transported to the shower. CNA 4 later stated she must not have fully checked that the resident was covered and acknowledged the importance of fully covering a resident for privacy and protection. The DON reviewed the facility policy and stated residents are to be covered for privacy while being transported to the shower, and that the facility policy was not followed when Resident 39’s buttocks was visible during transport.
Failure to Report Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse involving a resident who had a left below-knee amputation, diabetes mellitus, end stage renal disease, and dependence on hemodialysis. The resident’s record showed he was able to understand others and make himself understood, and he required extensive assistance from staff for bathing, dressing, toileting, transfers, and mobility. The resident also had care plans addressing emotional distress related to alleged mental abuse and fall/injury risk related to weakness and his left BKA. The allegation arose after a CNA placed the resident on a bedpan and left to assist another resident. When the CNA returned, the resident was upset and stated, “You wanted to throw me out of the bed.” In a later interview, the resident stated the CNA had been angry, rough with him, and almost pushed him out of the bed while he was on the bedpan and calling for help. The CNA stated the resident accused her of trying to push him out of the bed while she was changing him, and she acknowledged that allegations of abuse must be reported to ensure investigation and documentation. The DON stated the facility protocol required allegations of abuse to be reported to CDPH, the ombudsman, and police, and that the CNA should have reported the resident’s allegation. The ADM stated she was not aware of the allegation because it was not brought to her attention, and she stated that if she had known, she would have followed the abuse protocol. During follow-up review, the ADM stated the allegation should have been reported immediately or within 2 hours, but it was not, and there was no documentation of follow-up, the CNA was not suspended, the resident was not interviewed, and the physician was not notified. The facility policy stated that suspected abuse must be reported immediately, defined as within 2 hours for allegations involving abuse or physical harm/serious bodily injury.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of staff-to-resident abuse involving a resident who was admitted with diagnoses including left below-knee amputation, DM, ESRD, and dependence on HD. The resident’s MDS indicated he could understand others and make himself understood, and the H&P stated he had the capacity to understand and make decisions. His care plan identified him as at risk for emotional distress related to alleged mental abuse and at risk for falls and injuries related to weakness and left BKA. The allegation arose after a CNA placed the resident on a bedpan and left to assist another resident. When the CNA returned, the resident was upset about the delay in response to the call light and later stated, “You wanted to throw me out of the bed.” In interviews, the resident stated the CNA was angry, rough with him, and almost pushed him out of bed while changing him. The CNA stated the resident accused her of trying to push him out of the bed, and she reported the incident to an RN and completed a Stop and Watch tool, but she could not recall whether she reported the resident’s abuse allegation. The resident later stated facility leadership did not talk to him about the incident. The DON stated the facility protocol for abuse allegations was to report to CDPH, the ombudsman, and police, monitor the resident, and suspend the staff member pending investigation. The DON also stated she was not aware the resident had alleged that the CNA tried to push him out of the bed, and that the allegation should have been reported and investigated. The ADM stated she was not aware of the allegation because the DSD did not inform her of the Stop and Watch tool, and that if she had known the resident said, “you wanted to throw me out of the bed,” she would have followed the abuse protocol. The ADM further stated the allegation should have been reported immediately or within 2 hours, the CNA should have been suspended, the resident should have been interviewed, documentation of follow-up should have been completed, and the physician should have been notified, but these actions were not done.
Missing PASARR Level II Care Plan
Penalty
Summary
The facility failed to ensure that Resident 3 had a PASARR Level II care plan to personalize the resident’s special needs. Resident 3’s record showed an original admission on 6/25/2024 and a readmission on [DATE], with diagnoses including MS, functional quadriplegia, schizophrenia, depression, and muscle wasting and atrophy. The H&P dated 2/06/2026 stated the resident had the capacity to make needs known but could not make medical decisions, and the MDS dated 5/02/2026 indicated the resident was cognitively intact and dependent on staff for all ADLs and transferring. The PASARR dated 2/06/2026 stated that facility staff would receive the Individual Determination Report, discuss the results in a timely manner, and incorporate the determination into the care plan. During interview and record review, the MDSC stated Resident 3 had a positive Level II and required a Level II evaluation, but the resident did not have a care plan specific to the PASARR Level II recommendations. The DON stated that a care plan should be developed for residents with PASARR Level II to ensure appropriate interventions and that the process should be completed within 48 hours of admission. The facility policy stated that all new admissions and readmissions are screened for MD, ID, or RD through the PASARR process and referred for Level II screening when indicated.
Failure to Resubmit PASARR Screening After Case Closure
Penalty
Summary
The facility failed to ensure that a resident with a positive PASARR Level I screening received the required Level II PASARR evaluation and determination. Resident 11 was admitted with diagnoses including unspecified psychosis, unspecified dementia, and falling. The resident's H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed the resident rarely or never could make herself understood, sometimes understood others, was dependent on staff for multiple ADLs, and was taking antipsychotic medication. Resident 11's PASARR Level I screening was positive for serious mental illness, and the notice stated that a Level II mental health evaluation was required. The notice further stated the facility would be contacted within two to four days to arrange an evaluator to review the resident's records and possibly complete a telephone contact or visit. A subsequent notice stated the facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening, so the case was closed and a new Level I screening had to be resubmitted to reopen the case. During interview, the MDS Coordinator stated that when the case was closed, one of the licensed nurses with access to the PASARR system should have resubmitted the Level I screening, but it was not done. The MDS Coordinator stated she was one of the nurses who could have resubmitted it, but she was not aware of the notice of attempted evaluation. The DON reviewed the facility PASARR policy and stated the policy was not followed when the facility did not follow up on the notice of attempted evaluation, which potentially resulted in a delay of specific interventions for mental, emotional, and psychosocial care for Resident 11.
Care Plans Did Not Match Physician Orders and Resident Language
Penalty
Summary
The comprehensive care plan for a resident with CMML, COPD, chronic respiratory failure with hypoxia, and PE did not reflect the physician’s order for continuous supplemental oxygen at 4 LPM via nasal cannula. The resident’s physician order summary showed an order for continuous O2 at 4 LPM, but the care plan for oxygen therapy listed an intervention for O2 at 2 LPM continuously. During observation, the resident was seen receiving O2 at 2 LPM via nasal cannula, and the resident stated she needed oxygen 24 hours every day. During concurrent review and interview, the RN stated the resident had an order for continuous O2 at 4 LPM and that the care plan intervention showing 2 LPM was not correct and did not match the physician’s order. The MDSC stated the care plan should indicate 4 LPM and acknowledged that the plan was not revised to reflect the order. The DON also reviewed the issue and stated the care plan did not indicate the correct amount of LPM for supplemental oxygen and that the facility’s policies and procedures were not followed. A second resident’s care plan did not reflect the resident’s correct primary language. The resident’s MDS showed Arabic as the preferred language, and the resident’s family member and CNA both stated the resident speaks Arabic. However, the care plan identified the resident as speaking Farsi. The MDSC and DON stated care plans must be individualized and accurately document the resident’s language, and both acknowledged that listing the wrong language could cause miscommunication about the resident’s care and treatment.
Unlabeled Urinal Bottle in Resident Room
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate assistance and services when a urinal bottle in the resident’s room was observed not labeled with the resident’s name. The resident was admitted with diagnoses including generalized muscle weakness, chronic kidney disease stage 4, and benign prostatic hyperplasia without lower urinary tract symptoms, and the history and physical indicated the resident had the capacity to understand and make decisions. During a concurrent observation and interview, the RN observed that the urinal was not labeled and stated that urinals should be labeled for infection control and to prevent them from being mixed up with other residents’ urinals. The RN discarded the urinal, obtained a new one, and labeled it with the resident’s name. Interviews with a CNA, the MDSC, and the DON all indicated that urinals are to be labeled with the resident’s name, that unlabeled urinals can be mixed up or used by other residents, and that this creates a risk for infection such as UTI or skin infection. The facility policy on cleaning and disinfecting non-critical resident-care items stated that single resident use items are for single resident use only and should be labeled with the resident’s name and/or room number.
Incorrect Labeling of Water Flush Bag for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure the water flush bag was labeled with the correct information for one sampled resident who had a feeding tube. Resident 47 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, and encounter for attention to gastrostomy. The resident’s H&P described the resident as alert with periods of confusion, and the MDS indicated the resident was rarely or never understood and was dependent with ADLs. Physician orders directed the resident to receive 80 mL/hr of water and 60 mL/hr of Diabetisource. During observation in the resident’s room, a flush bag hanging from a pole contained clear liquid but was labeled as Diabetisource. An LVN stated the flush bag label should include the rate, time, and date, and must state water instead of Diabetisource, and that using Diabetisource on the water bag label is confusing and may lead to errors. The DON stated the flush bag was incorrectly labeled as Diabetisource instead of water, which could cause confusion and possible errors in administering the correct rates for water. The facility policy titled Enteral Feeding via Continuous Pump stated it was intended to ensure the safe administration of enteral nutrition.
Oxygen Therapy Not Provided Per Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders and facility policy for two residents who were receiving oxygen therapy. Resident 9 had diagnoses that included COPD, chronic respiratory failure with hypoxia, CMML, and PE. The resident’s records showed a physician order for continuous oxygen at 4 LPM via nasal cannula, and the care plan identified continuous oxygen therapy at 4 LPM. However, during observations on 6/1/2026 and 6/2/2026, Resident 9 was found receiving oxygen at 2 LPM via nasal cannula instead of the ordered 4 LPM. During the 6/2/2026 observation, CNA staff stated the resident was usually on oxygen at 4 LPM, and the oxygen concentrator was observed set at 2 LPM. RN 3 reviewed the order and stated the resident should have been receiving 4 LPM, then entered the room and confirmed the oxygen was set at 2 LPM. RN 3 stated she had been in the room earlier and had not checked the concentrator setting. The DON later reviewed the oxygen administration policy and stated supplemental oxygen requires a physician’s order that includes the flow rate in LPM, and that the policy was not followed when Resident 9’s oxygen was not administered per the physician’s orders. Resident 114 had diagnoses that included acute respiratory failure with hypoxia, pulmonary edema, PE, and interstitial pulmonary disease. The record showed a completed order for initial oxygen at 2 LPM via nasal cannula for one day, but there was no active physician order to continue oxygen from 5/26/2026 through 6/1/2026. Despite this, the resident was observed receiving oxygen at 2 LPM via nasal cannula, and the chart contained oxygen saturation documentation on multiple dates while oxygen was in use. LVN 3 stated oxygen is considered a medication and requires a physician’s order, and that Resident 114 should have had an order to administer oxygen during that period. MDSC 1 stated there was no documented evidence that Resident 114 was monitored while on oxygen during that time, and the DON stated the facility policy requiring a physician’s order and monitoring was not followed.
Unclean Food Scooper Observed in Kitchen
Penalty
Summary
The facility failed to ensure that one of two food scoopers used for dry goods was clean. During a concurrent observation and interview in the kitchen with the Dietary Supervisor on 6/1/2026 at 8:06 a.m., surveyors observed one of the food scoopers sitting on top of a food preparation table with a white residue on it. The Dietary Supervisor stated that the food scooper must be cleaned after each use to prevent contamination risk to residents. Review of the facility policy and procedure titled "Sanitation," dated 2023, indicated that utensils shall be kept clean.
Incomplete Vital Sign Documentation in Resident Record
Penalty
Summary
The facility failed to maintain complete clinical records for one resident by not documenting the numeric values for vital signs taken during the night shift. Resident 110 was admitted with multiple serious diagnoses, including a displaced right femur fracture, right artificial hip joint, hypertension, congestive heart failure, atrial fibrillation, pleural effusion, acute respiratory failure with hypoxia, and mesothelioma. The resident’s admission/readmission initial assessment indicated he arrived by ambulance, was oriented to person, place, and time, and could follow simple commands with intermittent confusion. A progress note completed by RN 2 documented that during routine rounds at 11:00 p.m., the resident was lying in bed and breathing spontaneously with no signs or symptoms of respiratory distress, and that vital signs were assessed and within normal limits. The same note stated that at 4:00 a.m., a CNA found the resident pale and not breathing, and the resident was DNR. During record review and interviews, the MDS Coordinator and RN 2 stated that newly admitted residents’ vital signs are measured every shift and that the numeric values for HR, RR, BP, Temp, and O2 sat should have been documented. RN 2 acknowledged that she took the resident’s vital signs but missed documenting the numeric values. The DON reviewed the facility policy and stated that newly admitted residents have their vital signs measured every shift and the values are documented. The DON stated the resident should have had documented vital sign values for the night shift and did not. The facility policy on resident examination and assessment required vital signs and all assessment data to be recorded in the medical record, and the charting and documentation policy required documentation to be objective, complete, and accurate. The resident’s record therefore lacked complete documentation of the vital sign measurements that were reportedly obtained.
Nonfunctional Call Light for a Resident Needing Assistance
Penalty
Summary
The facility failed to ensure that the call light system was functional for one sampled resident, Resident 67. Resident 67’s record showed diagnoses including sepsis, muscle weakness, unsteadiness of feet, and UTI. The resident’s H&P stated the resident had the capacity to understand but could not make medical decisions. The care plan identified the resident as at risk for falls and injuries and included interventions to keep the call light within reach and to assess and anticipate toileting needs. Another care plan identified an ADL self-care and/or mobility performance deficit and included keeping the call light within reach and encouraging use of the call light for assistance. During a concurrent observation and interview, Resident 67 was found lying in bed with the call light button on the right side of the resident and the cord clipped to the sheet. The resident stated she had been calling for assistance all morning, nobody came in, and her adult brief was wet and needed to be changed. When the resident pressed the call light button, the notification light at the door did not light up. The call light cord was observed not connected to the wall-mounted control plate, and the end of the cord was severed and resting on top of the resident’s bed. Additional observations showed the severed call light cord remained visible on the bed while the SSA and later the AA entered and exited the room. When CNA 5 entered the room, the resident again stated she was wet and nobody came to assist. CNA 5 confirmed the call light was not functioning and stated the cord was broken and not connected to the wall. CNA 5 also stated staff entering the room are responsible for checking the call light and making sure it is functioning. The MDSC and DON both stated the call light should always be functioning and properly placed within reach, and the DON stated the facility policy was not followed when the resident’s call light was broken.
Failure to Verify Grilled Chicken Temperatures Before Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and sanitary food preparation practices by not verifying the internal temperature of grilled chicken before service. The facility’s menu for a specified week listed BBQ pork as the lunch entrée on a particular date, and grilled chicken was used as a substitute for residents who did not consume pork. During kitchen observations on that date, the cook (CK 1) was seen checking internal temperatures of foods on the tray line but did not check the internal temperature of the grilled chicken before plating and distribution. CK 1 later acknowledged in an interview that she did not check the temperature of the grilled chicken and recognized that failure to do so could result in residents becoming ill. Several residents were identified as receiving or potentially receiving the substituted grilled chicken. One resident with Alzheimer’s disease, type 2 DM, and HTN was on a regular, easy-to-chew diet with meat to be cut up and had documented dislikes of pork, ham, bacon, and sausage. Another resident with dysphagia, type 2 DM, and HTN had orders for a CCHO, NAS, minced and moist diet with mildly thick liquids for lunch only for oral gratification. A third resident, admitted with pancreatic cancer and muscle wasting/atrophy, had a regular puree diet with mildly thick liquids and documented dislikes of bacon, ham, and pork. A fourth resident with dysphagia, COPD, and CKD was on a CCHO, NAS, regular texture diet with thin liquids and had documented dislikes of pork chops and pork. These residents’ diet orders and documented dislikes made them candidates for the grilled chicken substitution instead of the scheduled pork entrée. On the observed lunch service date, CK 1 placed grilled chicken onto plates and into meal carts for distribution at specific times without verifying the internal temperature. Later, CK 1 placed a piece of grilled chicken into a blender to prepare a puree for a resident whose diet had been changed, again without prior temperature verification. The Dietary Supervisor stated in an interview that food temperatures should be taken at the tray line prior to service and that failure to do so means food may not be at required limits. The DON stated that food temperatures are to be taken before food goes out and that if not done, food may arrive at the wrong temperature, with potential for residents not eating, weight loss, hunger, gastrointestinal issues, and foodborne illness. Review of the facility’s “Meal Service” policy, last reviewed on a specified date, showed that Food and Nutrition Services staff are required to take food temperatures prior to meal service, with hot foods such as meats to be served at 160°F–180°F and hot entrées to be above 120°F at delivery, which was not followed for the grilled chicken.
Failure to Monitor and Document Residents After Change of Condition and to Follow Oxygen Therapy Orders
Penalty
Summary
Licensed nurses failed to monitor and document the medical status of two residents following changes of condition (COC). For one resident with diagnoses including type 2 diabetes mellitus, anemia, and COPD, there was no documented evidence of monitoring after COCs related to low hemoglobin and hematocrit levels, a mass on the left arm, and later, high blood urea nitrogen, low potassium, and high ammonia levels. The facility's records showed that required monitoring every shift for 72 hours post-COC was not performed or documented on several shifts following these events. Additionally, the same resident had a physician's order for continuous oxygen therapy at two liters per minute via nasal cannula. However, documentation revealed that oxygen was administered at three liters per minute, contrary to the physician's order. This deviation from the prescribed oxygen therapy was acknowledged by both the LVN and the DON during interviews and was not in accordance with the facility's policy and procedure for oxygen administration. For another resident admitted with gastro-esophageal reflux disease, anemia, and hypertension, there was a failure to monitor and document the resident's gastrointestinal status after a COC involving two days of diarrhea. Progress notes indicated missing documentation for several shifts over a three-day period following the COC. The DON confirmed that monitoring and documentation were not completed as required by facility policy, which mandates monitoring and documentation of residents' progress and responses to treatment after a COC.
Failure to Adhere to COVID-19 Infection Control Protocols
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols related to COVID-19. One certified nursing assistant (CNA) was observed exiting a COVID-19 isolation room without wearing an N95 mask. The CNA reported that she had removed and disposed of all personal protective equipment, including the N95 mask, inside the isolation room, contrary to facility policy which requires PPE to be removed and replaced outside the isolation room. The resident in the isolation room had a diagnosis of COVID-19 and other medical conditions, with intact cognition, and had recently tested positive for COVID-19. Additionally, a licensed vocational nurse (LVN) was observed at a nurse station not wearing the N95 mask properly; the mask was under the chin and not covering the nose and mouth. The LVN also touched the outside of the mask and then used the computer keyboard without performing hand hygiene. Both the Director of Staff Development and the Director of Nursing confirmed that N95 masks should be worn properly in all patient care areas, including nurse stations, and that hand hygiene should be performed after handling soiled masks. Facility policies reviewed indicated that staff must wear well-fitted N95 respirators during respiratory outbreaks and perform hand hygiene after handling soiled equipment or contaminated objects.
Call Light Not Accessible for High Fall Risk Resident
Penalty
Summary
A resident with a history of hemiplegia and hemiparesis following cerebrovascular disease, as well as type 2 diabetes mellitus and essential hypertension, was identified as having severely impaired cognitive skills and a high risk for falls. The resident's care plan specifically required that the call light be kept within reach and that staff encourage its use for assistance, with prompt responses to all requests. However, during an observation, the call light was found rolled up and hung on the wall at the head of the resident's bed, out of the resident's reach. The Director of Nursing confirmed that the call light was not accessible to the resident and acknowledged that the call light is a primary means for residents to communicate with staff. Facility policy also required that call lights be accessible to residents when in bed, on the toilet, or in the shower. The failure to ensure the call light was within reach represented a lack of reasonable accommodation for the resident's needs and preferences, as outlined in both the care plan and facility policy.
Failure to Individualize Nutrition Care Plan for Resident Food Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with multiple diagnoses, including type 2 diabetes mellitus, depression, and epilepsy. Upon admission, the resident's physician order specified a controlled carbohydrate, no added salt, regular texture diet with no fish. However, the facility's menu included fish for lunch, and the resident was served a meal containing fish. The resident's food preference for no fish was not documented on the meal ticket, and the Certified Nursing Assistant (CNA) was unaware of this preference until informed by a family member. The CNA then returned the tray to the kitchen for replacement. Further review revealed that the resident's care plan did not address the food preference for no fish, and the care plan on nutrition was not individualized. Both the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the resident's food preference should have been identified and documented during the admission process, and that the care plan should have been updated to reflect this preference. The facility's policy required comprehensive, person-centered care plans based on thorough assessments, but this was not followed in the resident's case.
Failure to Ensure Proper Administration and Documentation of Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cerebral palsy, hypotension, and heart failure did not receive their midodrine HCl 10 mg tablet as prescribed. The physician's order required the medication to be administered three times daily for hypotension, and the care plan reflected this intervention. On the day in question, the medication was documented as administered at 11:08 a.m., two hours after it was actually given at 9:08 a.m. During an observation, a white round pill identified as midodrine was found on the hallway floor outside the resident's room. The Director of Staff Development confirmed the pill's identity and noted that the nurse should ensure residents swallow their medications. Further review of the Medication Administration Record (MAR) with the LVN revealed that the medication was marked as not given, despite the bubble pack for that dose being empty. The LVN stated he believed he had given the medication with applesauce but acknowledged that documentation should occur before moving to the next resident. The facility's policy required medications to be administered and documented in a safe and timely manner, with the MAR initialed after each administration and before proceeding to the next medication. The failure to ensure the medication was properly administered and documented constituted a significant medication error.
Failure to Honor Resident's No Fish Dietary Preference
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus, depression, and epilepsy was admitted to the facility with a physician order specifying a controlled carbohydrate, no added salt, regular texture, and no fish diet. Despite this order, the resident's food preference for no fish was not documented on the Diet Communication Form, and the dietary department was not informed. On the day following admission, the facility's menu included fish for lunch, and the resident was served a meal containing fish. The meal ticket on the resident's tray did not indicate the no fish preference, and staff members, including a CNA and an LVN, were unaware of the resident's dietary restriction at the time the meal was served. The deficiency was further evidenced by interviews and record reviews showing that the resident's food preference was communicated by a family member to nursing staff on the night of admission, but this information was not relayed to the dietary department or reflected in the resident's dietary documentation. The dietary supervisor only updated the Diet Communication Form after being informed of the issue by the family member. The facility's policy required that dietary profiles include diet orders and food dislikes, but this was not followed, resulting in the resident being served a meal that did not accommodate their documented preference.
Failure to Investigate and Document Resident Grievance
Penalty
Summary
A resident with multiple sclerosis, schizophrenia, and bipolar disorder, who was assessed as having intact cognitive skills and the capacity to make decisions, reported an incident in which another resident touched his legs, causing him to feel scared and uncomfortable due to existing wounds in the area. The resident communicated this concern to an LVN, who then relayed the complaint to the Social Services Assistant (SSA). However, the SSA did not ask the resident about the complaint during their interaction and did not document the concern. A review of the facility's grievance policy indicated that all grievances and complaints must be investigated and documented, including the resident's account of the incident. The Director of Nursing confirmed that the complaint was not verified or investigated, and there was no documentation of the incident as required by policy. This failure to investigate and document the resident's grievance constituted a violation of the facility's procedures for addressing resident complaints.
Resident's Right to Refuse Care Not Respected
Penalty
Summary
A deficiency occurred when a resident's right to refuse care was not respected by facility staff. The resident, who had diagnoses including bilateral primary osteoarthritis of the knee, muscle weakness, and chronic pain, was dependent on staff for several activities of daily living and was always incontinent. On the morning in question, the resident expressed to staff that she did not want to be touched or have her incontinence brief changed, repeatedly telling the certified nursing assistant (CNA) to leave her alone. Despite these clear refusals, the CNA continued to attempt to check the resident's incontinence brief, pulling the blanket and attempting to proceed with care. Interviews with the resident, the involved CNA, another CNA who witnessed the incident, and the Director of Nursing (DON) confirmed that the resident's refusals were not honored. The CNA admitted to not respecting the resident's wishes and acknowledged that she should have left the resident alone and reported the refusal to the licensed nurse. The second CNA corroborated that the resident was vocal in her refusal and that the CNA continued with the care attempt despite this. The DON also confirmed that the resident's rights were violated by the CNA's actions. Facility policy review indicated that residents have the right to refuse care and must be treated with dignity and respect. The failure to honor the resident's refusal of care was contrary to both facility policy and the resident's rights, as documented in the facility's own procedures and confirmed by staff interviews.
Failure to Provide Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, Resident 85 and Resident 34, who were part of the Restorative Nursing Assistant (RNA) feeding program. These residents were assisted with eating in the rehabilitation therapy room, which contained multiple walkers, a weighing scale, parallel bars, and electric bikes, rather than in a more appropriate setting like the bistro room. The bistro room was being used as an office and employee lounge, which was intended to be a temporary arrangement. This setting did not align with the facility's policy to provide a personalized, homelike environment. Additionally, the facility did not maintain a clean and safe environment for Resident 248, who had a fracture of the right tibia and required substantial assistance with activities of daily living. The resident's left floor mat was found to have dried black particles and a tear, which were not addressed by the housekeeping department or staff responsible for cleaning spills. This oversight was contrary to the facility's policy of maintaining a clean, safe, and homelike environment, as well as the manufacturer's guidelines for cleaning fall mats after each use. These deficiencies were identified through observations, interviews, and record reviews, highlighting the facility's failure to adhere to its policies and procedures regarding maintaining a homelike environment. The presence of institutional characteristics and unclean conditions in the residents' living spaces had the potential to violate their rights to a safe, comfortable, and homelike environment.
Improper Use of Restraints Without Orders or Consent
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, affecting four residents. For two residents, the facility did not have a physician's order, informed consent, restraint assessment, or care plan for the use of a bed placed against the wall, which was considered a restraint. The staff placed the beds against the wall to prevent falls and accommodate wheelchairs, but this restricted the residents' freedom of movement and was done without the necessary documentation and consent. For the other two residents, the facility used wedge pillows placed under the fitted sheets, which acted as restraints by preventing the residents from moving freely or getting out of bed. The staff used these pillows for repositioning but placed them in a way that the residents could not remove them, effectively restraining them without a physician's order, informed consent, or a care plan. This practice was acknowledged by the staff and the Director of Nursing as inappropriate and restrictive. The facility's policies and procedures require a physician's order, informed consent, and a comprehensive care plan for the use of physical restraints. However, these were not followed, leading to the improper use of restraints on the residents. The lack of adherence to these protocols resulted in the restriction of residents' freedom of movement and potentially increased the risk of harm.
Deficiencies in Care Plan Implementation and Medication Management
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in medication management and care. Resident 37 was prescribed methenamine hippurate for UTI prophylaxis, but no care plan was developed to ensure its safe use and prevent antibiotic resistance. This oversight was identified during a review of the resident's records, which showed moderate cognitive impairment and periods of confusion, highlighting the need for a structured care plan. Resident 7, who was prescribed trazodone for depression and insomnia, did not receive the non-pharmacological interventions outlined in their care plan. The care plan included various therapeutic and environmental interventions to address sleep issues, but these were not documented or implemented between February 1 and February 11, 2025. Similarly, Resident 53, who was on Haldol for schizoaffective disorder, did not receive the non-pharmacological interventions specified in their care plan for managing paranoia and verbal outbursts during the same period. Resident 55's care plan lacked measurable goals and monitoring for sleep hours despite being prescribed trazodone for major depressive disorder with insomnia. The absence of documented sleep monitoring from January 1 to January 30, 2025, meant that the effectiveness of trazodone could not be assessed, potentially leading to unnecessary medication use. Interviews with nursing staff and the Director of Nursing confirmed these deficiencies, emphasizing the importance of comprehensive care plans to maintain residents' well-being and limit unnecessary medication use.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards by not rotating insulin administration sites for two residents, leading to potential adverse effects. Resident 73, who was admitted with diagnoses including type 2 diabetes mellitus and congestive heart failure, had physician's orders to rotate insulin injection sites to prevent complications such as bruising and lipodystrophy. However, the Medication Administration Record (MAR) indicated that the insulin was repeatedly administered in the same areas, contrary to the physician's orders and manufacturer's guidelines. Similarly, Resident 63, who had type 2 diabetes mellitus and dementia, also received insulin injections without proper site rotation. The resident's care plan and physician's orders specified the need for site rotation to prevent skin complications. Despite these instructions, the Location of Administration Report showed repeated use of the same injection sites over several months. Interviews with the Director of Nursing and nursing staff confirmed the failure to rotate injection sites as per the guidelines and physician's orders. The facility's policy on insulin administration emphasized the importance of site rotation to avoid skin issues, yet this was not followed, leading to the identified deficiencies.
Failure to Limit Psychotropic Medication Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that the drug regimens for five of six sampled residents were free from unnecessary medications, as per the facility's policy and procedure. Specifically, the facility did not limit the use of lorazepam and Ativan for two residents to a 14-day period or specify a duration or stop date. This oversight was noted despite the facility's policy requiring a stop date for psychotropic medications to prevent unnecessary use. Additionally, the facility did not provide non-pharmacological interventions for residents using trazodone and Haldol, nor did it monitor the effectiveness of these medications by tracking symptoms or sleep patterns. Resident 71 was admitted with diagnoses including depression, dementia, and anxiety disorder. The resident was prescribed lorazepam without a stop date, which was against the facility's policy. Similarly, Resident 5, who was cognitively intact and diagnosed with hemiplegia, bipolar disorder, depression, and anxiety, was prescribed Ativan without a specified duration or stop date. These omissions were acknowledged by the facility's staff, who confirmed that the medications should have had a 14-day stop date or a specific duration to ensure they were not causing more harm than good. For Residents 7, 53, and 55, the facility failed to implement non-pharmacological interventions and monitor the effectiveness of psychotropic medications. Resident 7, diagnosed with depression and insomnia, was prescribed trazodone without documentation of non-pharmacological interventions. Resident 53, with schizoaffective disorder, was prescribed Haldol without monitoring the number of episodes of paranoia. Resident 55, using trazodone for depression-related insomnia, did not have a care plan goal for hours of sleep or documentation of sleep monitoring. These deficiencies in care planning and monitoring potentially led to the unnecessary use of psychotropic medications, as the facility did not assess the effectiveness of non-drug interventions or the medications themselves.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.9% error rate. This was due to two medication errors out of 29 opportunities, affecting one resident. The errors involved the administration of metoprolol and aspirin to Resident 196 at a time different from the physician's order. The medications were supposed to be given at 7:30 a.m. with food, but were administered at 9:39 a.m. without food, which was outside the facility's policy of a 60-minute window for medication administration. Licensed Vocational Nurse 5 (LVN 5) acknowledged the error during an interview, stating that the medications were administered later than the specified timeframe, which was confirmed by the Director of Nursing (DON). The facility's policy requires medications to be administered in a safe and timely manner, as prescribed, and within one hour of their prescribed time unless otherwise specified. The failure to adhere to these guidelines resulted in a medication error, as defined by the facility's policy, which includes administering medications at the wrong time.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. For one resident, the facility did not rotate the subcutaneous insulin administration sites as per the physician's orders and manufacturer's guidelines. This resident, who had type 2 diabetes mellitus and other health conditions, received insulin injections repeatedly in the same areas of the abdomen, contrary to the instructions to rotate sites to prevent complications such as bruising and lipodystrophy. The Minimum Data Set Nurse confirmed that the insulin administration sites were not rotated, which was a deviation from the physician's orders and standards of practice. Another resident also experienced similar issues with insulin administration. This resident, who had type 2 diabetes mellitus and cognitive impairments, received insulin injections without proper rotation of the administration sites. The facility's records showed multiple instances where the insulin was administered in the same areas, despite the physician's orders to rotate the sites. A Registered Nurse acknowledged that the staff failed to rotate the insulin administration sites, which is considered a medication error. The Director of Nursing confirmed that the facility's staff did not adhere to the physician's orders, manufacturer's guidelines, and professional standards regarding insulin administration. The facility's policies and procedures clearly defined medication errors as deviations from these standards, and the failure to rotate insulin administration sites was identified as such an error. The facility's documentation and interviews with staff highlighted the lack of compliance with established protocols, leading to the identified deficiencies.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. The Dietary Supervisor (DS) noted that food items in the walk-in refrigerator were not labeled according to facility policy. Specifically, a white bag containing a cookie and a small bowl of grapes were found unlabeled, which is against the facility's policy that requires all items removed from their original packaging to be labeled with contents, preparation date, and expiration date. This oversight could lead to serving expired or allergenic foods to residents. Additionally, the facility did not adhere to its policy regarding the storage of used cloths and towels. During the kitchen observation, two dry white towels, one with a dry brown substance, were found on top of a meat slicer. The DS stated that towels should be stored in a sanitization bucket when in use and not left on kitchen equipment, as this poses a risk of cross-contamination. The Director of Nursing (DON) confirmed that improper towel storage is an infection control issue that could lead to resident illness. The facility also failed to maintain the walk-in freezer temperature as per policy. The DS observed a build-up of ice around the freezer door gasket and on the ceiling, indicating that the freezer temperature was not consistently maintained. This could result in thawing and refreezing of stored meat, affecting its quality. The facility's policy requires freezers to be maintained at temperatures below zero degrees, and the presence of ice build-up suggests that this standard was not met.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a kitchen facility task. On two separate occasions, surveyors observed multiple large dumpsters outside the facility with trash bags placed on the ground behind them. The trash included disposable gloves, dirty rags, a Styrofoam cup, and a food wrapper. During interviews, staff members, including a janitor, the Infection Preventionist (IP), the Maintenance Supervisor (MS), and the Director of Nursing (DON), acknowledged that trash should be placed inside the dumpsters to prevent contamination and the attraction of pests. The janitor stated that the trash bags were left outside because the dumpsters were full, although they were found to be empty upon inspection. The IP, MS, and DON all emphasized the importance of keeping trash inside closed containers to prevent the spread of infection and the attraction of insects and rodents. The facility's policy and procedure, as well as the Food Code 2022, require that garbage and refuse be stored in a manner inaccessible to pests and that dumpsters be kept closed and free of surrounding litter.
Failure to Provide Privacy Cover for Urinary Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident, identified as Resident 249, by not providing a privacy cover for the resident's urinary drainage bag. Resident 249 was admitted with diagnoses including a urinary tract infection, unsteadiness on feet, and generalized muscle weakness, and required assistance with all activities of daily living. The resident had an indwelling catheter for urine retention, and the facility's policy required that urinary catheter drainage bags be covered to preserve the resident's dignity. During an observation, it was noted that Resident 249's urinary catheter drainage bag was hanging on the side of the bed without a privacy cover. The Quality Assurance Nurse confirmed the absence of the privacy cover and acknowledged that it should have been placed upon admission. The Director of Nursing also stated that the lack of a privacy cover was a dignity issue, as it could affect the resident's self-worth and self-esteem. The facility's policy emphasized the importance of promoting dignity and assisting residents in maintaining their sense of well-being.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure the call light was within reach for a resident, leading to a deficiency in accommodating the resident's needs and preferences. The resident, admitted with a fracture of the right tibia, unsteadiness on feet, and generalized muscle weakness, was identified as having severely impaired cognition and required substantial to total assistance with activities of daily living. The care plan for the resident, who was at high risk for falls, included an intervention to keep the call light and bed controls within easy reach to prevent falls. During an observation, the call light was found on the floor, out of the resident's reach, which was confirmed by RN 3. The RN acknowledged that the call light should have been clipped to the bed sheet and within the resident's reach to prevent delays in care. The Director of Nursing also confirmed that staff should ensure call lights are accessible to residents before leaving the room. The facility's policy on answering call lights emphasized the importance of ensuring call lights are accessible to residents in various locations, including from the bed and floor, and that timely responses to residents' requests and needs are essential.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to maintain resident privacy during medication administration, affecting two residents. During observations, it was noted that the privacy curtains between the beds of the residents and their roommates were left open while medications were being administered. This oversight occurred with two different Licensed Vocational Nurses (LVNs) administering medications to the residents. The failure to close the privacy curtains potentially exposed the residents' treatment and care to unauthorized individuals, which could lead to psychosocial harm. Resident 5, who was cognitively intact, had a history of hemiplegia, hemiparesis, bipolar disorder, depression, and anxiety. Resident 196, who had mild cognitive impairment and was feeling down and depressed, had diagnoses including hypertension, atrial fibrillation, and dysphagia. Both LVNs acknowledged their failure to ensure privacy during medication administration, and the Director of Nursing confirmed the importance of safeguarding resident dignity by maintaining privacy during medical care. The facility's policy and procedures emphasized the need to respect residents' private space and property at all times.
Failure to Update Care Plan for Nutritional Intervention
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident 6, to include updated interventions for nutrition. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, contractures, and visual loss, experienced a significant weight loss of 15% over 180 days. A nutrition assessment recommended the administration of LiquaCel, a protein supplement, to address this weight loss. However, the care plan, last revised on February 7, 2025, did not reflect this intervention, as confirmed by a registered nurse during a review. The Director of Nursing acknowledged that the care plan was not updated to include the LiquaCel intervention, which was ordered on February 12, 2025. The oversight was attributed to the licensed nurse who carried out the order but failed to update the care plan. The facility's policy requires that care plans be revised as residents' conditions change to ensure all staff are aware of current interventions. The failure to update the care plan had the potential to delay necessary interventions for the resident's nutritional needs.
Failure to Prevent and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, identified as Resident 12, who was at risk for developing pressure injuries and had a pre-existing stage 4 sacral ulcer. The resident's care plan required turning and repositioning every two hours to prevent further skin breakdown. However, the facility staff did not consistently adhere to this schedule, as evidenced by multiple entries in the Turn and Reposition Log that lacked documentation of the resident's position or indicated that the resident was not turned every two hours as required. Observations and interviews revealed that Resident 12 was often found in positions not aligned with the posted turning schedule, and staff failed to document the resident's refusal to turn or the reasons for such refusals. On several occasions, the resident was observed lying in the same position for extended periods, contrary to the care plan's directives. Additionally, the use of improper equipment, such as ordinary pillows instead of wedge pillows, was noted, which did not adequately relieve pressure on the resident's buttocks. Interviews with staff, including LVN 1, CNA 6, and the Director of Nursing, confirmed the lapses in following the care plan and documentation requirements. The staff acknowledged the importance of turning the resident every two hours and documenting any refusals to prevent the worsening of the pressure ulcer. The facility's policy and procedure on repositioning emphasized the need for accurate documentation and adherence to the care plan, which was not followed in this case.
Failure to Ensure Safe Environment and Accurate Fall Risk Assessment
Penalty
Summary
The facility failed to ensure a safe environment for Resident 19 by improperly placing fall mats in their room. During an observation, it was noted that a drawer was placed on top of the fall mat, and there was a gap between the bed and the mat, which could lead to the resident falling directly onto the floor. The Registered Nurse confirmed that the fall mat should be placed directly at the exit side of the bed to prevent injury, and the presence of furniture on the mat could cause significant harm if the resident were to fall. The Director of Nursing also acknowledged the improper placement of the fall mat and the potential for injury due to the furniture on top of it. For Resident 66, the facility failed to accurately complete a fall risk assessment and conduct an interdisciplinary team (IDT) meeting after fall incidents. The fall risk assessment on one occasion was not completed accurately, as it did not reflect the resident's history of falls, which should have resulted in a higher risk score. Additionally, there was no documentation of IDT meetings being conducted after fall incidents, which are necessary to determine the cause of falls and implement appropriate interventions. The Minimum Data Set Nurse and the Director of Nursing both confirmed the absence of these critical assessments and meetings. The facility's policies and procedures require that fall risk factors be documented and that IDT meetings be conducted after fall incidents to identify causes and implement interventions. However, these procedures were not followed for Resident 66, placing the resident at risk for further falls and potential injuries. The lack of accurate assessments and timely IDT meetings indicates a failure to adhere to established protocols designed to ensure resident safety.
Failure to Ensure Proper Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a potential risk of urinary tract infection (UTI). The resident, admitted with diagnoses including UTI, unsteadiness on feet, and generalized muscle weakness, required assistance with activities of daily living and had an indwelling catheter for urine retention. During an observation, it was noted that the resident's urinary catheter tubing had a loop while hanging on the side of the bed, which was verified by the Quality Assurance Nurse (QAN). The QAN confirmed that the loop in the catheter tubing could prevent urine from flowing freely, potentially causing a UTI. The Director of Nursing (DON) stated that urinary catheter tubing should be positioned properly to prevent loops or kinks, as improper positioning could lead to urine backing up into the bladder. The facility's policy on catheter care emphasized the importance of keeping the catheter and tubing free of kinks and ensuring proper drainage. Despite these guidelines, the staff failed to ensure the resident's catheter tubing was free of loops, which was a direct violation of the facility's policy and posed a risk for the resident's health.
Improper Labeling of Water Flush Bag for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure proper labeling and administration of a water flush bag for a resident with a feeding tube, identified as Resident 22. The resident, who was admitted with conditions including gastrostomy, acute kidney failure, and dysphagia, had a feeding tube in place. The resident's Minimum Data Set indicated severe cognitive impairment and highly impaired vision, affecting their ability to make decisions. During an observation, it was noted that the water flush bag was labeled only with the date and time, lacking the resident's name, room number, and the rate of infusion, which are necessary to ensure accurate administration and prevent over or under hydration. Interviews with the Registered Nurse and the Director of Nursing confirmed that the labeling was incomplete and did not comply with the facility's policy and procedure for enteral feedings. The facility's policy required that water flush bags be labeled with specific information, including the resident's name, room number, and rate of administration, to prevent errors. The failure to adhere to these protocols had the potential to result in altered nutritional status and gastrointestinal infection for the resident.
Deficient Respiratory Care Practices
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For Resident 22, the suction canister was not labeled with the date it was last changed. This oversight was observed during an interview with LVN 3, who acknowledged that the canister should be dated to prevent prolonged use, which could lead to the growth of microorganisms and potential respiratory infections. The Director of Nursing (DON) confirmed that the canister should be changed every seven days or as needed, according to the facility's policy. For Resident 346, the oxygen tubing was not labeled with the date it was last changed and was found touching the floor, while the nebulizer mask and tubing were not stored in a plastic bag with the resident's name and date. During an observation with CNA 3 and LVN 1, it was noted that the tubing was inside the trash can, and both staff members agreed that the tubing should be dated and stored properly to prevent infection. The DON reiterated that the tubing should be changed every seven days or as needed and should not be in contact with the floor or trash. The facility's policy on respiratory therapy and infection prevention, last reviewed in 2024, requires labeling and changing of oxygen cannula, tubing, and nebulizer equipment every seven days or as needed. The failure to adhere to these standards poses a risk of infection due to improper handling and storage of respiratory equipment.
Failure to Reconcile Controlled Substances and Verify Accountability Logs
Penalty
Summary
The facility failed to properly reconcile a medication emergency kit containing controlled substances in one of the inspected medication carts. During an observation and interview with a Licensed Vocational Nurse (LVN), it was revealed that the emergency kit was not reconciled as part of the controlled substances inventory at every shift change, as required. The LVN acknowledged the importance of reconciling controlled substances to ensure accountability and prevent diversion or accidental exposure to residents. Additionally, the facility did not include verifying signatures from the Director of Nursing (DON) or a Registered Nurse (RN) on the Medication Count Sheet accountability logs for controlled substances awaiting disposal. During an interview, the DON admitted that the logs lacked signatures, which are necessary to ensure each controlled substance dose is accounted for until disposal. The facility's policies and procedures require controlled substances to be counted at the end of each shift and for the medication disposition record to contain witness signatures, which were not adhered to in this case.
Failure to Monitor Antibiotic Prophylaxis for UTI
Penalty
Summary
The facility failed to ensure that a licensed pharmacist provided a recommendation on the use of methenamine hippurate as a prophylaxis for urinary tract infection (UTI) for a resident. The resident, who was admitted with diagnoses including thrombocytopenia, gastro-esophageal reflux disease, and cerebral infarction, had been on methenamine hippurate since September 2023 without an order for monitoring signs and symptoms of UTI to evaluate its effectiveness. The resident's Minimum Data Set indicated moderate cognitive impairment and the use of a high-risk drug class antibiotic. During interviews and record reviews, it was revealed that the Infection Preventionist (IP) and the Consultant Pharmacist (PHARM) had differing views on whether methenamine hippurate is an antibiotic or antibacterial. The PHARM stated that there should be renal function monitoring and monitoring for signs and symptoms of UTI to ensure the medication's effectiveness as a prophylaxis. However, the facility did not conduct such monitoring, nor did they follow up with the attending physician regarding the prolonged use of the medication. The facility's policy on Antibiotic Stewardship, last reviewed in June 2024, indicated that the consultant pharmacist should include medication safety criteria in the monthly medication regimen review. Despite this policy, the facility did not adhere to these guidelines, resulting in the risk of the resident receiving excessive dosages of methenamine hippurate, which could lead to adverse effects and potential hospitalization.
Failure to Monitor Methenamine Hippurate Use in Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the use of methenamine hippurate as a prophylaxis for urinary tract infections (UTIs). The resident, who was admitted with diagnoses including thrombocytopenia, gastro-esophageal reflux disease, and cerebral infarction, was prescribed methenamine hippurate without adequate monitoring for signs and symptoms of UTI. The medication was used for an excessive duration without an end date or proper monitoring, which could lead to adverse effects from its continued use. Interviews with the Infection Preventionist and the Consultant Pharmacist revealed discrepancies in the understanding of methenamine hippurate's classification and the necessary monitoring protocols. The Consultant Pharmacist emphasized the need for renal function monitoring and regular checks for UTI symptoms to ensure the medication's effectiveness and prevent adverse effects. The facility's policy on antibiotic stewardship was not adequately followed, as there was no monitoring for signs and symptoms of UTI, and the staff did not follow up with the physician regarding the prolonged use of the medication.
Inconsistent Hospice Care for Resident
Penalty
Summary
The facility failed to ensure consistent provision of necessary care for a resident receiving hospice services. The resident, who was admitted with diagnoses including malignant neoplasm of the colon, acute and chronic respiratory failure, and type 2 diabetes mellitus, was under hospice care with a plan that required hospice aide visits twice a week. However, during the week of January 19 to January 25, 2025, the hospice aide visited only once, on January 22, 2025, instead of the scheduled two visits. This inconsistency in care was confirmed during interviews with Registered Nurses 4 and 1, who noted the absence of documentation explaining the missed visit. The Director of Nursing acknowledged that the missed hospice aide visit could potentially affect the resident's choice for care and their mental and psychosocial well-being. The facility's policy on hospice care emphasizes the importance of coordinated care plans that reflect the resident's goals and wishes, including palliative goals and interventions. The failure to adhere to the hospice plan of care, as outlined in the facility's policy, highlights a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being.
Infection Control Deficiencies in Labeling and Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two main deficiencies. Firstly, a resident's urinal bottle was not labeled with the resident's name and room number, which is a necessary measure to prevent cross-contamination. During an observation, the urinal was found hanging on the side rail without any identification, and both the treatment nurse and the Director of Nursing acknowledged that this oversight could lead to the switching of urinals between residents, potentially causing cross-contamination and infection spread. The facility's policy requires that single resident-use items be labeled to prevent such issues. Secondly, during a tour of the laundry area, it was observed that clean linens, clothing, and curtains were improperly placed on the floor in the Clean Linen Folding Area. This included clean donation clothing in a plastic bin, clean resident room curtains in plastic bags, and clean clothing in cardboard boxes, some of which were touching the floor. The Maintenance Supervisor and the Infection Preventionist both confirmed that clean linens should not be placed on the ground as it could lead to contamination from dirt and bacteria, which could then be transferred to residents, potentially causing illness. The facility's policy clearly states that clean linens should be stored and handled in a way that prevents cross-contamination. These deficiencies highlight lapses in the facility's adherence to its own infection control policies, which are designed to ensure a safe and sanitary environment for residents. The failure to label personal items and properly store clean linens poses a risk of spreading infections among residents, as acknowledged by the facility staff during interviews.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse reporting policy and procedure by not reporting an allegation of injury of unknown origin to the State Survey Agency within the required two-hour timeframe. This deficiency involved a resident who was originally admitted with a dislocation of an internal left hip prosthesis and a fracture of the left femur neck, among other diagnoses. The resident, who had severely impaired cognition and was dependent on staff for activities of daily living, experienced severe pain and possible hip displacement, leading to a discharge to a general acute care hospital for further evaluation and treatment. Despite the unusual occurrence of the resident's left hip dislocation, the facility did not report the incident to the State Survey Agency as required by their policy. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, revealed that the incident was not reported, and an investigation was conducted internally. The facility's policy mandates immediate reporting of suspected abuse, neglect, or injury of unknown origin to the administrator and relevant authorities, but this protocol was not followed in this case.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to promote the residents' right to examine the results of the most recent survey by not posting the survey results in a prominent and accessible location. This deficiency was identified during an interview with four resident council attendees who stated they did not know where to examine the most recent survey results. The Activity Director confirmed that the survey results, which were previously placed in front of the business office, had been removed due to wall painting, and a sign was posted indicating the results were available upon request. Further interviews revealed that the survey results were not readily available, although the facility had them and would provide them upon request. The Director of Nursing emphasized the importance of making state inspection results available for residents, visitors, and the public to understand the expected care standards. A review of the facility's policy indicated that the most recent survey results should be maintained in a 3-ring binder in an area frequented by most residents, such as the main lobby or resident activity room.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 2,888 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newhall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Astoria Healthcare Center | 6.2 mi | ★★★★★ | 29 | 0 |
| Mountain View Conv Hosp | 6.5 mi | ★★★★★ | 39 | 0 |
| Rinaldi Convalescent Hospital | 6.6 mi | ★★★★★ | 35 | 0 |
| The Grove Post-acute Care Center | 6.9 mi | ★★★★★ | 40 | 0 |
| Magnolia Gardens Convalescent Hospital | 6.9 mi | ★★★★★ | 34 | 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 October 2026) and official state health department websites.