Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southland during CMS and state inspections, most recent first.
A resident with severely impaired cognition, a cognitive communication deficit, and abnormal posture had a mattress placed on the floor next to the bed that was not covered and was visibly damaged, with discoloration and worn/peeled protective layers. A CNA said it appeared to have been cleaned multiple times, and the ADM and DON stated they were aware of the mattress and that it should not have been there; the DON said it was not pleasing to the eye and could be a dignity issue.
Insufficient staffing led to delayed call light response and missed hygiene care. A resident who needed help with showers went for weeks without bathing, while several residents reported waiting up to 10 to 30 minutes for call lights to be answered. The DON stated call lights should be answered immediately, and staff described short staffing, including call-offs without replacement and heavy weekend evening workloads.
Food items were found improperly dated, labeled, and sealed in dry storage, the refrigerator, and the freezer, including opened pasta, marshmallows, cream cheese, sour cream, dinner rolls, and vegetables. The DS stated that food should be labeled and sealed per facility storage guidelines, but several items lacked required dates or had incorrect dates. The facility also had a quaternary sanitizer bucket reading 150 ppm, below the 200 ppm level the DS stated was needed for effective sanitation.
A CNA provided indwelling catheter care to a resident on EBP without wearing the required gown, and a laundry staff member handled and distributed clean linen between resident rooms without performing hand hygiene. The residents involved had significant medical and cognitive impairments, and the DON stated staff should use appropriate PPE for catheter care and perform hand hygiene before and after handling clean linen.
Failure to Protect Resident Privacy During Urination: A resident with pneumonitis, DM2, and major depressive disorder was observed using a urinal in bed with his private area exposed when he pulled the urinal out. The resident stated he preferred the room door remain closed except while eating, yet the care plan included opening the curtain and door while using the urinal. CNA, LVN, RNS, and DON interviews confirmed the exposure and that the facility did not document alternative interventions to protect the resident’s privacy and dignity.
A facility failed to obtain complete informed consent before giving psychotropic medications to two residents. One resident with dementia, depression, anxiety, and psychosis had incomplete consent forms for Depakote and Quetiapine, with missing consent documentation and signatures. Another resident with impaired cognition and diagnoses including depression, anxiety, and psychosis had no informed consent on file for Duloxetine and Gabapentin. The DON confirmed the missing consent documentation during record review.
Delayed call light response and missed showering preferences: A resident who needed substantial help with showers and valued bathing choice went about two weeks without a shower. Three other residents reported that call lights were not answered in a timely manner, with waits ranging from about 10 to 30 minutes. The DON stated call lights should be answered immediately, and the facility policy required response within a reasonable time.
Advance directives were not properly addressed for one resident and were missing from the records of two others. A resident who was cognitively intact and had capacity to make decisions was not given written AD information, while two other residents had ADs noted in social services documentation but no copies were found in either the electronic record or the paper chart. The SSD said she provided only verbal AD education unless written information was requested, and the DON stated ADs need to be in the chart so staff know residents’ wishes.
A resident receiving Depakote had a vague order for mood swings, but staff said the behavior was not monitored with a measurable resident-specific indicator in the MAR. In addition, two residents receiving psychotropic medications had no regular IDT review to assess continued need, justification, or possible GDR, and the RN supervisor and DON stated the IDT did not meet to discuss psychiatric behaviors or whether treatment or medications should be changed.
PASARR Assessment Not Followed Through for Resident With Mental Illness: A resident with major depressive disorder, acute respiratory failure, and PVD had an H&P showing no capacity to make decisions and an MDS showing extensive assistance needs. The PASARR Level I indicated serious mental illness and required a Level II evaluation, but a Notice of Attempted Evaluation stated the resident had no serious mental illness. The DON acknowledged the conflicting information, stated the resident should have been reassessed, and said the PASARR process was missed.
Failure to Include Dental and Wound Care in Care Plans: A resident with cerebral palsy and cognitive impairment had repeated difficulty cooperating during dental visits, including closing his mouth, spitting, and moving his head, but the care plan did not address the need for extra time or support during dental services. Another resident with DM, CKD, and depression had a surgical left knee incision requiring daily dressing changes, but the care plan did not include wound treatment goals or interventions. Staff and the DON acknowledged the missing care plan focus for both residents.
Improper Foley Catheter Bag Positioning: A resident with a Foley catheter and severely impaired capacity had the drainage bag observed touching the floor during one observation and held above bladder level during repositioning during another. CNA and therapy staff confirmed the bag placement, and the DON stated the bag should be kept off the floor and below bladder level to prevent urine backflow and infection risk.
A nurse gave a resident acetaminophen instead of the ordered Norco for 8-10 pain after the resident refused the offered opioid, and the DON stated nurses cannot adjust doses without a physician order. The facility also failed to replace an emergency kit within the required 72 hours after it was used for another resident’s insulin lispro dose.
Failure to address consultant pharmacist MRR recommendations for a resident with dementia, psychosis, and mood disorder. Staff did not document that the Seroquel target behavior was clarified after the pharmacist said “sudden angry outburst” was vague and subjective, and there was no evidence the recommendation was acted on. The pharmacist also recommended a GDR for Depakote, but the MD marked disagreement without documenting the rationale, clinical indication, or date of review, and the DON stated there was no record of a specific response addressing the dose.
Controlled Medication Not Properly Locked: A resident’s Ativan was found stored in an unlocked medication refrigerator during an observation in the med room. The resident had severely impaired cognition and was dependent on staff for all ADLs. The facility policy required Schedule IV meds to be kept in separately locked, permanently affixed compartments.
Kitchen staff failed to follow a resident’s meal ticket and could not verbalize substitute fortified food items for cheese. During trayline, a CK placed shredded cheese on a resident’s tray even though the ticket indicated the resident disliked cheese. Another CK and the DS were unable to identify substitute fortified items for cheese, despite the resident being on a fortified, lactose-free diet and the meal ticket containing the resident’s preferences and diet order.
A resident with DM, legal blindness, and impaired cognition had a CCHO soft and bite-sized diet with thin liquids ordered due to aspiration risk, but family-brought food was found stored in the room, including bananas, tangerines, and cookies. Staff observed the items were not kept in the designated area, some bananas were old and discolored, and the resident reported mosquitoes in the room. The unit manager and DON stated outside food must be monitored, handled, stored, and supervised according to the resident’s diet order.
Damaged Headwall Molding in Resident Room: A resident with severely impaired capacity and dependence on staff for ADLs was found with damaged molding at the head of the bed. A CNA observed exposed inner materials, and housekeepers confirmed the damage and said it could not be properly disinfected. The IP and DOM noted the issue had not been entered for repair in the maintenance logs.
Pest Control Failure With Rodent Droppings in Resident Laundry: A resident with Parkinson’s disease and moderate cognitive impairment had rodent droppings found in her laundry hamper and clothing after FM collected her laundry from the facility, and one shirt was chewed through. FM reported the resident’s meal-related food spillage may have attracted rodents, and the DON stated rodents are never acceptable and are unsanitary.
A resident admitted for joint replacement surgery aftercare, with intact cognition but needing substantial/maximal assistance with ADLs, had a blank clothing and possessions inventory form at admission, despite having clothing present. Review of records showed the Resident's Clothing and Possessions form was not completed as required by the facility's Theft and Loss policy, which mandates a written personal property inventory upon admission. CNA staff confirmed the resident had belongings, and the DON acknowledged the form should not have been left blank, resulting in the resident’s possessions not being documented.
A resident with a prior femoral head arthroplasty, intact cognition, and need for substantial/maximal assistance with ADLs developed right hip pain with slight swelling, documented on a change of condition form. A radiology report later confirmed a superior lateral dislocation of the right hip. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the event met criteria for an injury of unknown origin but did not report it to CDPH, despite a facility abuse prevention policy requiring training and reporting of injuries of unknown source.
A resident with intact cognition and a history of joint replacement aftercare, who required substantial/maximal assistance with ADLs, reported right hip pain with slight swelling. An x-ray later showed a superior lateral dislocation of the right hip in the setting of a femoral head arthroplasty. The ADON interviewed only the treatment nurse and one LVN, and did not interview the resident, CNAs, or the PT who worked with the resident at the time of the complaint. The Administrator acknowledged that no investigation of the hip dislocation was conducted, despite a facility policy requiring prompt and thorough investigation of all allegations of abuse or neglect.
A resident with a UTI and intact cognition had a physician’s order for a BMP and CBC that was completed, with blood drawn and results reported. Later, a phlebotomist mistakenly drew the resident’s blood again using the same prior order, without a new physician order, after finding both white and yellow copies of the lab requisition in the lab binder. The DON and ADON described a process in which white copies should be removed after labs are drawn and yellow copies left in the binder, but older requisitions were not routinely removed, and the phlebotomist reported she did not verify the date on the requisition or consult staff. The facility had a policy for obtaining and arranging diagnostic tests but lacked a specific procedure for how phlebotomists should conduct blood draws.
Staff and visitors did not consistently follow infection control protocols, including proper use of PPE and hand hygiene, during a COVID-19 outbreak. A resident with COVID-19 required assistance, but staff were observed not wearing required gowns and gloves, improperly donning PPE, and reusing N-95 masks. Additionally, a staff member was seen without a mask inside the facility, and a delivery person entered without a mask or hand hygiene, with no infection control supplies available at the entrance.
Two residents, both with cognitive impairments, were involved in a physical altercation when one intentionally pushed her wheelchair into the other after a verbal exchange. Staff observed and reported the incident internally, but facility leadership did not report the abuse allegation to authorities within the required two-hour window, as mandated by policy, because they did not consider it abuse. This delayed reporting prevented immediate investigation by regulatory authorities.
The facility did not investigate a reported physical altercation between two residents, one with severe cognitive impairment and another with moderate impairment, after staff observed and reported the incident to nursing leadership. Despite facility policy requiring prompt investigation of alleged abuse, the Administrator did not initiate an investigation or report the event, resulting in unresolved issues between the residents.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
The QAA Committee did not identify or implement corrective actions for systemic issues, including infection control lapses during the Covid-19 outbreak, inadequate assessment of dialysis patients before and after treatment, and failures in preventing, reporting, and investigating abuse allegations, affecting all residents.
Staff failed to consistently follow infection prevention protocols, including not wearing required PPE such as gowns and eye protection when providing care to residents on Enhanced Barrier Precautions or in COVID-19 isolation, not covering a peripheral venous catheter hub, and delaying contact isolation for a resident with scabies. Missing signage and improper storage in the clean linen area were also observed, with staff interviews confirming lapses in protocol awareness and adherence.
A cockroach was found in a resident's room, with housekeeping staff confirming previous sightings and the administrator identifying it as a cockroach. The DON stated that pests should not be present in resident rooms, as it compromises cleanliness and safety. Facility policy requires efforts to control pests, but this was not achieved.
Multiple residents were not treated with dignity and respect, including a resident whose catheter bag was left uncovered, another who was kept in a hospital gown and not groomed, and a resident with a colostomy who was found with soiled clothing and unclean teeth. Staff interviews and facility records confirmed that assistance with personal hygiene and grooming was not consistently provided, contrary to facility policy.
A resident with dementia was found to have multiple topical medications at her bedside and was self-administering them without a physician's order or documented assessment of her ability to do so. Nursing staff confirmed that no evaluation or authorization had been completed, and facility policy requiring assessment and documentation for self-administration was not followed.
Two residents with significant physical and cognitive impairments were found to have call lights placed out of their reach, preventing them from requesting assistance when needed. Staff confirmed the call lights should have been accessible, and facility policy required call lights to be within reach before staff left the room.
A resident with severe cognitive impairment and multiple medical conditions had a grievance filed by a family member regarding the actions of a CNA, but the facility failed to address, investigate, or resolve the complaint for over 50 days. The Social Services Director, responsible for grievance oversight, was not informed of the grievance, and the issue was not logged or followed up as required by facility policy.
Two residents did not have comprehensive care plans addressing their specific needs, including range of motion limitations after a fracture and ongoing edema. One resident's care plan lacked interventions for limited shoulder movement and did not address repeated refusals of orthopedic follow-up, with missed documentation and IDT meetings. Another resident with leg swelling had no care plan for edema, despite staff awareness. These deficiencies were confirmed through interviews, record reviews, and observations.
Two residents with significant physical and cognitive impairments did not receive necessary assistance with grooming and oral hygiene. One resident was left in a hospital gown with unkempt hair for an extended period, while another was not assisted with toothbrushing and had dirty teeth, with documentation confirming oral care was not provided as required.
A resident with diabetes and ESRD experienced multiple episodes of uncontrolled blood glucose, including hospitalization, due to the facility's failure to monitor and document self-administration of insulin via an insulin pump as required by policy. Another resident with a left arm fracture did not receive timely orthopedic follow-up, with missed and undocumented appointment refusals, leading to prolonged non-weightbearing status and delayed rehabilitation. Staff interviews revealed inconsistent processes for monitoring, documentation, and interdisciplinary communication.
A resident with a history of left humerus fracture and limited left shoulder mobility did not receive required ROM services, as quarterly joint mobility assessments failed to include the affected shoulder and no restorative nursing aide interventions were implemented, despite physician orders and ongoing limitations. Staff interviews and resident reports confirmed the lack of assistance with arm exercises, and facility policies for assessment and care planning were not followed.
A resident with an indwelling foley catheter and a history of urinary tract issues was not monitored or assessed for signs and symptoms of a urinary tract infection, despite care plan requirements and facility policy. Medical record review showed no documentation of urine assessment, and staff interviews confirmed the lack of monitoring for infection.
Several residents requiring hemodialysis did not receive care according to professional standards, including a resident who missed a scheduled dialysis session and developed fluid overload, a resident with a dialysis catheter left uncovered, another resident not properly assessed before and after dialysis, and a resident without necessary emergency supplies at the bedside. These deficiencies were confirmed through observation, record review, and staff interviews.
Two restorative nursing aides lacked competency in locating PPE for a resident on Enhanced Barrier Precautions, resulting in failure to use required isolation gowns during care. The aides were unaware of the resident's precaution status and did not know the new PPE storage location, as their training did not cover this change. The facility's infection prevention and nursing leadership confirmed the omission in competency training and the importance of proper infection control practices.
Surveyors found that the facility exceeded the acceptable medication error rate, with errors involving two residents. In one case, a nurse failed to administer vitamin B1 and gave an incorrect dose of vitamin B12, while in another, a nurse did not clarify or follow instructions for dissolving MiraLAX, using the wrong water volume. These errors occurred due to failure to follow physician orders, medication labels, and facility policy.
Two residents did not receive their prescribed medications as ordered, including missed doses of Eliquis for one resident on dialysis days and missed administration of Levothyroxine for another resident over several days. Nursing staff confirmed the medications should have been given according to physician orders, but this did not occur.
Surveyors found that medications were not consistently stored or labeled according to manufacturer specifications and facility policy. For example, a vial of eye drops was stored with rectal suppositories in a medication cart, and a bottle of ophthalmic solution lacked an open date and was not refrigerated as required. In medication room refrigerators, several drugs were kept at temperatures below recommended ranges, and a bottle of prednisolone eye drops was improperly refrigerated. Staff interviews confirmed these practices did not meet professional standards and facility policy.
Expired Italian dressing, barbeque sauce, and caramel sauce were found stored in a facility refrigerator, and several resident food items, including coffee creamers and a peanut butter sandwich, were not properly labeled with resident information as required by policy. Staff interviews confirmed that expired food should be discarded and only resident food, properly labeled, should be stored in the designated refrigerator.
A resident with a history of left humerus fracture and surgical repair did not have an accurately completed Joint Mobility Assessment, as the severity of range of motion loss in the left shoulder was not documented despite physician clearance for ROM exercises. Additionally, the resident's orthopedic consultation progress note was missing from both the physical and electronic medical records, leaving staff without access to critical recommendations and the plan of care.
The facility did not complete required McGeer's Criteria documentation for two residents who received intravenous antibiotics for infections, leaving relevant sections of the Infection Surveillance forms blank. The IPN did not verify if hospital-ordered antibiotics met the criteria, and the DON confirmed that such verification is required by facility policy.
Three residents were not properly documented as having received education, consent, or administration of influenza and pneumonia vaccines. In one case, a consent form was signed by a family member but the vaccine was not given; in other cases, there was no evidence that vaccines were offered or consented to. Interviews with the IP nurse and DON confirmed that the required documentation and tracking were not completed, despite facility policy requiring education, consent, and administration of these immunizations.
The facility did not document education or administration of the COVID-19 vaccine for two residents, including one with dementia and another with moderate cognitive impairment. In one case, a family member requested the vaccine be given later, but this was not documented, nor was the vaccine ordered. Facility policy requires documentation of education and consent for immunizations, which was not followed in these instances.
A resident with severe cognitive impairment was subjected to a nonconsensual kiss by another resident and experienced isolation due to staff actions. The facility did not assess, monitor, or provide emotional support to the resident after these incidents, nor did it follow required procedures for reporting and investigating abuse allegations.
Damaged mattress left on the floor in resident room
Penalty
Summary
The facility failed to ensure that a mattress placed on the floor next to one resident’s bed was not damaged. The resident had diagnoses including a cognitive communication deficit and abnormal posture, and the MDS dated 5/22/2026 indicated the resident’s cognition was severely impaired. The resident required supervision or touching assistance with eating, oral hygiene, and personal hygiene, and was dependent for showering/bathing and upper body dressing. During an observation of the resident’s room on 5/28/2026 at 1:36 p.m., surveyors noted a mattress on the floor next to the resident’s bed. The mattress was not covered with a sheet or other covering, had a large white discolored area in the middle, the top protective layer was worn off, and the right upper side was peeled off. A CNA stated on 5/29/2026 at 1:30 p.m. that the mattress appeared to have been cleaned multiple times, which caused the top layer to wear off. The ADM and DON stated on 5/29/2026 at 3 p.m. that they were aware of the mattress and that it should not have been there; the DON also stated the resident’s room should be homelike and that the mattress on the floor was not pleasing to the eye and could be a dignity issue.
Insufficient staffing and delayed call light response
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet residents’ needs and to have a licensed nurse in charge on each shift. Surveyors found that Resident 35 had not been showered for several weeks, and that call lights for Residents 60, 63, and 123 were not answered in a timely manner. The report states these failures had the potential to result in a delay in care and services. Resident 35 was admitted with diagnoses including difficulty walking, abnormal posture, blindness of the right eye, generalized muscle weakness, and paraplegia. His MDS indicated intact cognition and that he needed substantial assistance with showering. During interview, Resident 35 stated he had not showered for a couple of weeks and that call light response could be slow, with staff sometimes saying they would return but not coming back. A review of documentation showed Resident 35 showered on 5/5/2026, and the prior shower before that was on 4/21/2026, about 2 weeks earlier. Resident 60 was admitted with diagnoses including aftercare following joint replacement surgery, osteoarthritis of the right knee, difficulty walking, and major depressive disorder. Her MDS showed moderately impaired cognition and dependence or assistance with several ADLs, including showering. She stated staff sometimes took up to 30 minutes to respond to her call light. Resident 63, admitted with gastrointestinal stromal tumor, difficulty walking, and abnormal posture, and Resident 123, admitted with muscle weakness, difficulty walking, COPD, and abnormal posture, also reported slow call light response times during the resident council meeting. Staff interviews and records reflected short staffing, including nurses calling off without replacement staff, CNAs sharing assignments, and weekends from 3 p.m. to 11 p.m. being especially hard because admissions often occurred during that shift.
Food Storage and Sanitizer Concentration Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner by not ensuring that food items in dry storage, the walk-in refrigerator, and the walk-in freezer were properly dated, labeled, and sealed. During observation with the Dietary Supervisor, opened dry pasta in a plastic container had no receiving date, open date, or used-by date; opened Lasagna dry pasta in a box had a receiving date but no open date or used-by date; and opened marshmallows in a plastic bag had a receiving date and used-by date but no open date. The Dietary Supervisor stated that all food items should be labeled with receiving dates and used-by dates, and that opened items should be tightly closed to prevent contamination. In the walk-in refrigerator, opened cream cheese in a zip lock bag was unsealed and unlabeled with no receiving date or open date, and opened sour cream in a plastic container had a receiving date but no open date and an incorrect used-by date. In the walk-in freezer, opened dinner rolls and California mixed vegetables were found in opened plastic bags inside boxes and were not sealed properly. The Dietary Supervisor stated that refrigerated and frozen items should be sealed properly and dated according to the facility’s storage guidelines. Facility policies reviewed during the survey required food in storerooms, refrigerators, and freezers to be labeled and dated, with opened dry foods tightly closed and refrigerated and frozen foods stored according to the applicable storage guidelines. The facility also failed to maintain the proper concentration of quaternary ammonium in the sanitizing bucket near the dishwasher sink. During observation, the Dietary Supervisor tested the solution and the strip indicated 150 ppm, while the Dietary Supervisor stated it should read 200 ppm to be effective. The Regional Registered Dietitian Nutritionist stated that sanitizing buckets should contain the proper chemical concentration to kill microorganisms effectively. The facility’s policy stated that the quaternary solution should be tested at least every shift or when cloudy and replaced when the reading is below 200 ppm.
Infection Control Practices Not Followed During Resident Care and Linen Handling
Penalty
Summary
The facility failed to ensure infection control practices were followed for four sampled residents. Resident 5 had diagnoses including diastolic heart failure, type 2 diabetes mellitus, and obstructive uropathy, and was assessed as moderately cognitively impaired and dependent on staff for toileting hygiene, with maximal assistance needed for showering and supervision for personal hygiene. The resident had an indwelling catheter to a closed drainage system and was on enhanced barrier precautions, with the care plan directing staff to use gowns and gloves for all personal care. During observation, CNA 2 provided indwelling catheter care and emptied the drainage bag for Resident 5 without wearing the required gown while the resident was on enhanced barrier precautions. CNA 2 acknowledged not wearing the required gown during the care. In an interview, the DON stated residents with indwelling catheters are at high risk for infection and that staff should wear appropriate PPE, including a gown, while providing indwelling catheter care as part of infection control. Laundry staff 1 was observed handling and distributing clean linen between resident rooms without performing hand hygiene. The staff member removed clean linen from the linen cart, placed linen inside Resident 89's wardrobe cabinet, touched the wardrobe doors and linen cart multiple times, then went to the shared room of Residents 154 and 157 and handed clean linen to another staff member inside without washing or sanitizing hands in between. The DON stated handwashing is the number one standard precaution and that staff should perform hand hygiene before and after handling and distributing clean linen and before moving between resident rooms. The facility's policies identified hand hygiene as a standard precaution, described enhanced barrier protection as requiring gown and gloves during high-contact resident care activities, and stated clean linens are to be kept covered and protected from contaminants and not come in contact with staff clothing.
Failure to Protect Resident Privacy During Urination
Penalty
Summary
The facility failed to protect the privacy and dignity of one resident while he was urinating. Resident 1 was admitted and later readmitted with diagnoses including pneumonitis, type 2 diabetes mellitus, and major depressive disorder. The resident’s H&P stated he had the ability to understand and make decisions, and the MDS indicated mildly impaired cognition, supervision assistance with one activity, moderate assistance with personal hygiene, and maximal assistance with toileting hygiene. During an observation in front of the resident’s room, the resident was sitting in bed using a urinal between his legs and pulled the urinal out, which exposed his private area while he was holding the urinal. CNA 3 entered the room at that time. The resident stated others could not see because a table was positioned in front of him and stated a preference for the room door to remain closed except while eating. The care plan included an intervention entered on 5/4/2026 stating the resident preferred to have the privacy curtain open and the door open while using the urinal. RNS 3 stated that this intervention was not acceptable because the facility remained responsible for implementing reasonable interventions to protect the resident’s privacy and dignity. LVN 3 stated CNA 3 reported the resident’s private area was exposed while urinating, and there was no documentation that alternative interventions were attempted. CNA 3 confirmed the resident did not want others to see his private area. The DON stated the facility should provide privacy and dignity while the resident was exposing his private part for urination on the bed.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering psychotropic medications to two sampled residents, Resident 7 and Resident 60. Resident 7’s record showed diagnoses including dementia, major depressive disorder, anxiety disorder, and psychosis, and the H&P noted fluctuating capacity to understand and make decisions. The MDS showed the resident required extensive assistance with multiple activities of daily living. During record review, the psychotherapeutic drug informed consent form for Depakote 250 mg twice daily was incomplete, with the consent/decline section left blank and missing the signature, relationship, and date of the person giving consent; the form also lacked the name of the licensed nurse who obtained telephone consent. Resident 7 also had a psychotherapeutic drug informed consent form for Quetiapine Fumarate 50 mg at bedtime for psychosis, but the form was incomplete as well. Although phone consent was noted from the RP, the consent/decline box and the date of telephone consent were not documented. The DON stated there was an older consent for Quetiapine Fumarate, but a new consent was being sought due to changes in monitoring target behavior. The DON and RNS both stated the consent forms were not completed because of missing information, and the DON stated the consent should be completed prior to starting the medication. Resident 60’s record showed diagnoses including aftercare following joint replacement surgery, major depressive disorder, anxiety disorder, and unspecified psychosis. The MDS indicated moderately impaired cognition, with the ability to understand others and make herself understood, and the resident required varying levels of assistance with activities of daily living. The active medication orders included Duloxetine HCl 60 mg twice daily and Gabapentin 800 mg every 6 hours, but the DON stated Resident 60 did not have informed consent for either medication and that informed consent should be obtained prior to administration of psychotropic medications. Facility policies reviewed stated that informed consent should be obtained before initiation of psychotherapeutic or psychotropic medications.
Delayed call light response and missed showering preferences
Penalty
Summary
The facility failed to meet residents’ needs and preferences for bathing and timely response to call lights for four sampled residents. Resident 35, who had diagnoses including spondylosis with radiculopathy, difficulty walking, abnormal posture, blindness of the right eye, generalized muscle weakness, and paraplegia, was assessed as cognitively intact and needing substantial assistance with showering. The MDS also documented that choosing a shower, tub bath, bed bath, or sponge bath was very important to the resident. Review of the documentation survey report showed the resident showered on 5/5/2026, and the prior shower was on 4/21/2026, about two weeks earlier. The LVN reviewing the record stated the resident needed substantial assistance with showering and that staff needed to respect residents’ preferences to shower for hygiene reasons. Residents 60, 63, and 123 reported delayed call light response times. Resident 60, who had diagnoses including aftercare following joint replacement surgery, osteoarthritis of the right knee, difficulty walking, and major depressive disorder, had moderately impaired cognition and required assistance with multiple ADLs, including dependent assistance with showering; the resident stated call light response was a problem and sometimes required waiting 30 minutes. Resident council minutes also documented the complaint that call lights were not answered in a timely manner. Resident 63, with diagnoses including gastrointestinal stromal tumor, difficulty walking, and abnormal posture, had moderately impaired cognition and required varying levels of assistance with eating, oral hygiene, personal hygiene, toileting hygiene, and showering; during resident council, Resident 63 stated call light response time was slower than before and could take as long as 10 minutes. Resident 123, with diagnoses including metabolic encephalopathy, muscle weakness, difficulty walking, COPD, and abnormal posture, had intact cognition and required supervision with toileting hygiene and showering; the resident also stated call light response time was a problem and could be as long as 10 minutes. The DON stated call lights need to be answered immediately, and the facility policy stated call lights will be answered within a reasonable time.
Advance Directives Not Discussed or Filed in Resident Records
Penalty
Summary
The facility failed to discuss and provide written information on advance directives for one resident who was admitted with diagnoses including morbid obesity, diabetes mellitus, and hypertensive heart disease. The resident’s H&P stated the resident had the capacity to understand and make decisions, the MDS indicated the resident was cognitively intact, and the POLST indicated the resident did not have an AD. During interview, the SSD stated she provided only verbal AD education and written education only upon request, and that she did not provide a written acknowledgement form to verify when residents received AD education. The SSD also stated that if residents are not provided with AD education, their medical decisions may not be honored in an emergency. The DON stated that if the resident is not provided with AD education, the resident’s rights may be violated and the resident’s end-of-life wishes may not be honored if the resident became unable to make medical decisions and a representative could not be identified. The facility policy stated it was the facility’s policy to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident’s option, formulate an advance directive. The facility also failed to ensure advance directives were included in the electronic and physical medical records for two residents. One resident’s records showed the resident was alert and oriented, and the Social Services Assessment/Evaluation indicated the resident had an advance directive, but no advance directive was uploaded electronically and no copy was present in the physical chart. Another resident’s MDS showed intact cognition, and the Social Services Assessment/Evaluation indicated the resident had advance directives, but no copies were found in either the electronic record or the physical chart. Staff stated the copies needed to be in the medical records so staff would know the residents’ wishes, and the DON stated advance directives need to be in the chart so the residents’ wishes are known.
Unclear behavior monitoring and missed IDT review for psychotropic medications
Penalty
Summary
The facility failed to define and monitor resident-specific, measurable target behaviors related to Depakote for one resident. The resident’s face sheet listed diagnoses including major depressive disorder, anxiety disorder, psychosis, and dementia, and the H&P noted fluctuating capacity to understand and make decisions. The MDS indicated severe cognitive impairment. The MAR showed an order for Depakote 250 mg twice daily for mood disorder manifested by mood swings, but the RN supervisor stated that mood swings was vague, did not provide a measurable resident-specific indicator for monitoring, and that episodes of mood swings were not monitored in the MAR. The DON also stated that mood swings was vague and did not provide a clear resident-specific parameter for monitoring. The facility also failed to ensure regular IDT conferences were held to assess continued need, justification, and possible gradual dose reduction for psychotropic medications for two residents. One resident had diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis, with moderately impaired cognition on the MDS. Active orders included duloxetine, gabapentin, buspirone, trazodone, and monitoring for episodes of depression and anxiety each shift. Another resident had a diagnosis of major depressive disorder, intact cognition on the MDS, and active orders for mirtazapine and nortriptyline, along with monitoring for episodes of depression every evening and night shift. During interview and record review, the RN supervisor stated psychiatric behaviors were monitored and documented daily, but no one tallied the behaviors at the end of the month and the IDT did not meet to discuss residents’ behaviors. The DON stated the IDT did not meet to discuss psychiatric behaviors to determine whether treatment needed to be changed or medications altered. The facility policy stated the IDT would review psychotropic medications and that residents would be calendared quarterly thereafter, or with significant change of condition, for IDT review to assess continued need/justification and possible gradual dose reduction.
PASARR Assessment Not Followed Through for Resident With Mental Illness
Penalty
Summary
The facility failed to follow through with and accurately assess Preadmission Screening and Resident Review (PASARR) requirements for one resident. The resident was admitted and readmitted with diagnoses including major depressive disorder, acute respiratory failure, and peripheral vascular disease. The history and physical indicated the resident did not have the capacity to understand and make decisions, and the MDS showed the resident required extensive assistance with transfers, bed mobility, personal hygiene, showering, dressing, and supervision or touching assistance for eating. During interview and record review, the DON reviewed the resident’s PASARR Level I, which indicated serious mental illness and that a Level II evaluation was required. The DON stated the resident should have had a Level II done based on the Level I assessment. A Notice of Attempted Evaluation was also reviewed and indicated the Level II could not be completed because the resident had no serious mental illness. The DON stated this was conflicting information and that the resident should have been reassessed, and acknowledged the PASARR assessment was not followed through and was missed. The record also showed a care plan for PASARR Level II status, a psychiatry consult order, and an order for Duloxetine for depression.
Failure to Include Dental and Wound Care in Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure a person-centered care plan was implemented for a resident with cerebral palsy, failure to thrive, and benign prostatic hyperplasia who was documented as moderately impaired in cognitive functioning and dependent for many self-care and mobility tasks. Dental consult notes showed the resident required additional time for dental services because of poor cooperation, including closing his mouth, spitting, moving his head, and being unable to keep his mouth open for extended periods during treatment. The resident’s comprehensive care plan did not include a focus for the need for additional time during dental services, and it did not contain goals or interventions to support dental visits or address the resident’s difficulty cooperating with dental personnel. During interview, the RNS stated there should have been a care plan for the dental issue because the resident was uncooperative during dental visits and needed a plan with goals and interventions for dental consults. The facility also failed to ensure a person-centered care plan was implemented for another resident who had diabetes mellitus, chronic kidney disease, depressive disorder, and a surgical wound on the left knee incision site after surgery. The order required daily cleansing with normal saline, patting dry, applying xeroform, and covering with a dry dressing for 14 days, but the comprehensive care plan did not include a focus on wound treatment, goals, or interventions to support the incision care and daily dressing changes. During interview, the LVN and DON stated there should have been a care plan for the treatment orders and wound care to identify the problem, guide staff, and allow revision if the wound was not improving.
Improper Foley Catheter Bag Positioning
Penalty
Summary
The facility failed to ensure proper urinary indwelling catheter care for one sampled resident with an indwelling catheter. Resident 80 was admitted and later readmitted with diagnoses including acute posthemorrhagic anemia, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS dated 4/5/2026 indicated the resident’s capacity was severely impaired and that the resident was dependent on staff for eating, oral hygiene, toileting hygiene, and showering. The order summary showed an indwelling catheter to a closed drainage system beginning 3/30/2026, and the care plan identified the resident as high risk for UTI with interventions to position the catheter drainage bag and tubing below bladder level. During observation, the resident’s urine drainage bag was seen touching the floor, and CNA 1 confirmed it was on the floor and stated it should be kept off the floor for infection control. On another observation, OTA 1 was seen holding the urine drainage bag above the resident’s bladder level while PT 1 repositioned the resident, then placing the bag between the resident’s legs while assisting him to sit up. PT 1 later confirmed OTA 1 kept the drainage bag above bladder level during repositioning. The DON stated staff were expected to keep the urine drainage bag off the floor and below bladder level to prevent urine backflow and reduce infection risk. The facility policy also stated staff should keep tubing below bladder level.
Medication Administration and Emergency Kit Replacement Failures
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when a nurse administered the wrong pain medication dose to a resident. The resident had diagnoses including fibromyalgia, headaches with orthostatic component, osteoporosis, arthropathy, and synovitis/tenosynovitis of the right upper arm, and the MDS indicated the resident had no impairment in cognitive skills for decision making. During observation, the resident reported 9/10 generalized pain and requested one tablet of acetaminophen. The nurse offered Norco, which was ordered for severe 8-10 pain, but after the resident refused, the nurse administered one 500 mg tablet of acetaminophen instead of following the ordered pain regimen. The nurse stated she did not follow the resident's medication orders and should have given Norco as ordered or notified the physician before giving the incorrect dose. The DON stated nurses cannot adjust dosages without a physician order. The facility also failed to ensure an emergency kit used for another resident was replaced within the required timeframe. The resident had type 2 diabetes, and the MDS indicated moderately impaired cognition and need for partial assistance with eating, oral hygiene, and personal hygiene. The resident's insulin lispro order was reviewed, and the emergency kit was observed opened in the medication room. The kit usage slip showed it had been accessed for the resident and 8 units of insulin lispro were removed. Staff stated the kit was replaced several days later, and one nurse stated it should have been replaced sooner in case the medication was needed again. The facility policy required the pharmacy to be notified and the kit replaced within 72 hours after use.
Failure to Address Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to address consultant pharmacist recommendations identified during the monthly medication regimen review for one resident with dementia, major depressive disorder, anxiety disorder, psychosis, and fluctuating capacity. The resident required extensive assistance with activities of daily living per the MDS. The consultant pharmacist’s 3/6/2026 review stated that monitoring behavior as “sudden angry outburst” for Seroquel was vague and subjective and should be clarified and made specific to the resident’s condition. During a concurrent interview and record review, the Registered Nurse Supervisor stated she was not sure the recommendation had been addressed and found no documentation or evidence that it was carried out. She stated staff were monitoring sudden angry outburst as the target behavior for Seroquel use, and that the licensed nurse who received the pharmacist recommendation should have acted upon it. The resident’s order summary showed quetiapine fumarate 50 mg at bedtime for psychosis manifested by sudden angry outburst, ordered on 12/30/2025. The consultant pharmacist’s 4/19/2026 review also stated the resident was receiving Depakote 250 mg twice daily from 12/30/2025 and that a gradual dose reduction was required to be attempted. The review stated that if the physician disagreed with the GDR, the rationale and clinical indication should be documented. The physician marked disagreement and signed without documenting the rationale, clinical indication, or date of review. The DON stated the staff or she should have followed through on the pharmacist’s recommendation, that there was no record of a specific response addressing the Depakote dosage, and that the resident had remained on the same dose since December 2025.
Controlled Medication Not Properly Locked
Penalty
Summary
The facility failed to ensure that one resident’s Ativan, a Schedule IV medication for anxiety, was properly stored in accordance with its controlled medication storage policy. During observation and interview in the first floor medication room, the resident’s Ativan was found in the medication refrigerator, which was not locked. The report states the medication was not in a locked container. Resident 84’s face sheet showed admission to the facility with a diagnosis of nonrheumatic aortic stenosis. The resident’s MDS dated 3/31/2026 indicated severely impaired cognitive skills and dependence on staff for all ADLs. The facility policy titled Controlled Medication Storage stated that Schedule IV medications are to be stored under separately locked and permanently affixed compartments separate from other medications.
Kitchen Staff Failed to Follow Meal Ticket and Identify Fortified Food Substitutes
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills related to following meal tickets and identifying substitute fortified food items. During a concurrent observation and interview in the trayline for lunch, CK 1 placed shredded cheese and extra shredded cheese on Resident 67’s tray even though the meal ticket indicated the resident disliked cheese. CK 1 stated she failed to check the meal ticket and should have reviewed and followed it. Resident 67’s record showed diagnoses including COPD, major depressive disorder, and chronic kidney disease, and the resident’s care plan and order summary included a regular texture, thin liquids, fortified, lactose-free diet with extra gravy/sauce ordered. The report also found that CK 2 and the Dietary Supervisor could not verbalize substitute fortified food items for cheese. During interview, CK 2 stated she was not sure what substitute fortified items could be used if residents could not eat cheese and said she would use butter if residents were allergic to dairy products. The Dietary Supervisor stated he could not recall substitute food items for fortified diet instead of cheese and could not think of substitutes, although he acknowledged fortified diet was intended to add extra calories to prevent weight loss. Both staff members stated they should have known the substitutes because residents could be lactose intolerant or allergic to dairy products. Resident 67 stated she did not like cheese because it caused her stomach to hurt really bad and that she had received dairy products in the past and did not eat the meal. She also stated she could not understand why kitchen staff did not follow the meal ticket containing her likes and dislikes. The Registered Dietitian Nutritionist stated the meal ticket contained the resident’s preferences, allergies, diet order, and preferred dining location, and staff should have read and followed it to avoid giving food items that might cause adverse health effects or dishonoring the resident’s preference. The facility’s competency documentation for CK 1 and CK 2 did not specifically address follow-through of the meal ticket or the list of fortified food item substitutes.
Visitor-Brought Food Not Controlled Per Diet Order
Penalty
Summary
The facility failed to ensure food brought in by visitors was monitored, stored, and supervised according to a resident’s prescribed diet order. Resident 36 was admitted with Guillain-Barre syndrome, type 2 DM, and legal blindness, and the MDS indicated moderately impaired cognition with setup assistance needed for eating and personal care. The resident’s orders included a consistent carbohydrate diet with soft and bite-sized texture and thin liquids due to aspiration risk, and the care plan directed staff to provide and serve the ordered diet and monitor intake. During observation, multiple food items brought by family were found in the resident’s room, including bunches of bananas, tangerines, and cookies, with some bananas described as well ripened and old with brown discoloration. The resident stated the family had brought the items a couple of days earlier. The unit manager observed the food items in the room and the resident stated there were mosquitoes in the room. The unit manager stated the food was not properly stored in the designated area and that the items were not consistent with the resident’s diet order due to their high sugar content. The DON stated the facility must monitor, handle, store, and supervise outside food brought by visitors to prevent harm, food borne illness, and pest attraction. The facility policy required food brought by family or visitors to be checked by nursing or dietary staff to ensure it did not conflict with the resident’s prescribed diet and to be stored and labeled appropriately.
Damaged Headwall Molding in Resident Room
Penalty
Summary
The facility failed to provide a safe environment for one resident when the molding located at the head of the resident’s bed was damaged. The resident’s face sheet showed admission and readmission to the facility with diagnoses including acute posthemorrhagic anemia, second-degree burn of the head, face, and neck, and chronic respiratory failure. The H&P dated 4/1/2026 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 4/5/2026 indicated the resident’s capacity was severely impaired and that the resident was dependent on staff for eating, oral hygiene, toileting hygiene, and showering. During observation on 5/4/2026, a CNA observed that the molding at the head of the resident’s bed was damaged and stated that the damaged headwall molding exposed inner materials and that particles could fall onto the resident. On 5/6/2026, two housekeepers confirmed the molding was damaged and were unsure when the damage occurred; one stated housekeeping could not disinfect damaged molding properly. The IP stated damaged molding should be repaired through maintenance to prevent paint and chips from falling onto the resident and that the damaged surface could not be properly disinfected until repaired. The DOM reviewed the maintenance logs and stated no repair request had been submitted for the damaged molding within the last four weeks. The DON stated the facility must provide a safe environment for residents to prevent injuries and ensure a safe surrounding environment.
Pest Control Failure With Rodent Droppings in Resident Laundry
Penalty
Summary
The facility failed to maintain a sanitary, pest-free environment when Family Member 1 found rodent droppings in Resident 105’s laundry hamper and among the resident’s clothes after collecting the laundry from the facility. One shirt was reported to have been chewed through in the chest area. Resident 105 was admitted with Parkinson’s disease, abnormalities of gait and mobility, cognitive communication deficit, difficulty walking, and abnormal posture, and the MDS dated 3/15/2026 indicated moderately impaired cognitive skills and need for assistance with multiple activities of daily living. Family Member 1 reported that Resident 105’s tremors and uncontrollable movements from Parkinson’s disease caused food to spill onto her shirt during meals, and that food remnants attracted rodents to her personal living space and clothing. The DON stated that rodents are never acceptable in the facility and that their presence is unsanitary and can negatively affect residents’ health and safety. The facility policy titled Pest Control stated it is the facility’s policy to provide an environment free of pests and that staff will monitor the environment.
Failure to Complete Resident Property Inventory on Admission
Penalty
Summary
Facility staff failed to complete a Resident's Clothing and Possessions inventory form for one resident at the time of admission, despite facility policy requiring a written personal property inventory upon admission. The resident’s face sheet showed she was admitted on a specified date with a diagnosis of joint replacement surgery aftercare, and her MDS dated 2/19/2026 indicated intact cognition and a need for substantial/maximal assistance with ADLs such as bathing, dressing, and toileting. Review of the Resident's Clothing and Possessions form dated 11/6/2025 showed the form was blank, even though the facility’s Theft and Loss policy from 4/2013 required that a written personal property inventory be recorded when a resident is admitted. During interviews, CNA 1 stated that the resident did have clothing at the time of admission, confirming that belongings were present but not documented. The DON stated that the Resident's Clothing and Possessions form should not be left blank and that staff should have documented whether the resident had any belongings or not. The lack of documentation on the inventory form meant the resident’s clothing and other possessions were not recorded upon admission, and the report states this had the potential for the resident to have no recourse to recover clothing or other possessions that could be lost.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the California Department of Public Health (CDPH) for one resident who experienced right hip pain that was later found to be a dislocation. The resident had been admitted with a diagnosis of joint replacement surgery aftercare and had a femoral head arthroplasty. An MDS assessment indicated the resident’s cognition was intact and that she required substantial/maximal assistance with ADLs. A Change of Condition form documented that the resident complained of right hip pain with intact skin and slight swelling. A subsequent radiology report showed a superior lateral dislocation of the right hip involving the prior arthroplasty. Interviews with facility leadership confirmed that the event met the definition of an injury of unknown origin and that it was not reported to CDPH. The ADON stated there was initially no explanation for the hip pain until the X-ray showed a dislocation, at which point it became an injury of unknown origin, but it was still not reported. The Administrator also stated that because there was no reason for the dislocation, it was considered an injury of unknown origin. The DON stated she believed the resident had reported hearing a pop during a transfer to bed and therefore did not report it as an injury of unknown origin, but later acknowledged there was no report of how the injury occurred. The facility’s abuse prevention policy indicated staff are to be trained on reporting abuse, neglect, exploitation, misappropriation, and injuries of unknown sources, including to whom and when such events must be reported.
Failure to Investigate Resident Hip Dislocation of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin when a resident with a history of joint replacement surgery aftercare reported right hip pain. The resident, who had intact cognition and required substantial/maximal assistance with ADLs, complained of right hip pain on a Change of Condition form dated 11/21/2025, which documented intact skin with slight swelling. A radiology report the following day showed the resident had a femoral head arthroplasty with a superior lateral dislocation of the right hip. Despite this significant injury, the Assistant Director of Nursing stated that only the treatment nurse and one LVN were interviewed regarding the resident’s hip pain, and that the resident, CNAs, and the physical therapist who worked with the resident on the date of the complaint were not interviewed to obtain additional information about the pain and dislocation. The Administrator confirmed that the incident involving the hip dislocation was not investigated, even though the facility’s abuse prevention policy required that all allegations of abuse, neglect, misappropriation of resident property, or exploitation be promptly and thoroughly investigated by the Administrator or designee.
Duplicate Lab Draw Performed Without New Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to prevent an unnecessary, duplicate blood draw for one resident after the original laboratory order had already been completed. The resident was admitted with a diagnosis of a UTI, and an MDS dated 12/4/2025 indicated the resident’s cognition was intact. A physician’s order dated 12/11/2025 directed that a BMP and CBC be drawn, and laboratory records showed the blood was collected on 12/11/2025 at 4:25 a.m., with results reported on 12/12/2025 at 12:43 p.m. Despite this, on 1/12/2026 the phlebotomist drew the resident’s blood again based on the same 12/11/2025 order, without a new physician order. A nursing progress note dated 1/13/2026 documented that when the resident inquired about lab results, staff checked the lab binder and discovered the phlebotomist had mistakenly redrawn the labs on 1/12/2026 using the already-completed 12/11/2025 order. Interviews and document review showed that the facility’s lab requisition handling contributed to the error. The DON explained that lab requisition forms have a white and yellow copy kept in a lab binder; when labs are drawn, the phlebotomist is supposed to remove the white copy and leave the yellow copy to indicate completion, and the yellow copies are not removed monthly but kept until the binder is full. The comprehensive test requisition for the 12/11/2025 labs was later signed and dated by the phlebotomist on 1/12/2026 to indicate another BMP and CBC collection, even though no new requisition existed for that date. The ADON reported that the phlebotomist admitted she did not pay attention to the color of the forms and only looked at the resident’s name, and the phlebotomist stated she saw both a white and yellow copy in the binder and assumed the white copy remained because the resident had previously refused or was unavailable. The phlebotomist also stated she did not clarify the date on the requisition with staff because no one was at the nurse’s station. The facility’s policy on Diagnostic Test Results Notification addressed obtaining and arranging labs when ordered, but the facility could not produce a policy or practice describing the procedure the phlebotomist should follow when conducting blood draws.
Failure to Enforce PPE and Infection Control Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its Infection Prevention and Control plan as outlined in its policy and procedures, specifically regarding the use of personal protective equipment (PPE) and adherence to standard and transmission-based precautions. Observations revealed that a resident admitted with COVID-19 infection required various levels of assistance from staff, yet staff did not consistently follow proper PPE protocols. For example, a Licensed Vocational Nurse was observed with her N-95 mask positioned below her chin, and a Certified Nurse Assistant (CNA) entered the COVID-19 positive resident's room without wearing a gown and gloves, later admitting she was unaware that the N-95 mask was for single use. The CNA also donned PPE incorrectly by putting on gloves before the gown, contrary to recommended procedures. Additional observations included another CNA not wearing a mask while inside the facility during a COVID-19 outbreak and a pharmacy delivery person entering the building without a mask or performing hand hygiene, with no infection control supplies available at the entrance. The Infection Prevention Nurse confirmed that all staff should wear N-95 masks upon entering the building and use appropriate PPE when indicated by signage. The facility's policy required standard and transmission-based precautions, hand hygiene, and proper selection and use of PPE, but these were not consistently followed as observed.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required two-hour timeframe after becoming aware of the incident. The event involved two residents, one with severe cognitive impairment and another with moderate cognitive impairment and a diagnosis of schizophrenia. The incident occurred when one resident, upset after being called a derogatory name, intentionally pushed her wheelchair into the other resident's wheelchair twice, causing the latter's head to move backward. Staff members who witnessed or were informed of the incident reported it up the chain of command, but the Assistant Director of Nursing and the Administrator did not consider the event to be abuse and therefore did not report it to the California Department of Public Health (CDPH) or other required authorities. The facility's policy and procedure required that all allegations or suspicions of abuse be reported immediately, but not later than two hours after the allegation is made, to both the facility Administrator and the State Survey Agency. Despite this, the Administrator acknowledged being notified of the incident but chose not to report it, as he did not consider it abuse. This failure to report resulted in the inability of CDPH to conduct an immediate investigation and created the potential for information to be lost or forgotten.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct an investigation after being made aware of a physical altercation between two residents. One resident, who had severe cognitive impairment and lacked decision-making capacity, was pushed by another resident with moderate cognitive impairment and the capacity to make decisions. The incident was witnessed by a CNA, who reported that the resident intentionally bumped her wheelchair into the other resident's wheelchair twice, causing the latter's head to move backward. The CNA reported the event to an LVN, who then informed the ADON. Despite these reports, the ADON and the Administrator did not consider the incident to be abuse and did not initiate an investigation. The facility's policy requires prompt and complete investigation of all alleged violations of abuse, neglect, exploitation, or mistreatment. However, the Administrator acknowledged being notified of the incident but chose not to report it to the appropriate authorities or begin an investigation, as he did not consider it abuse. This lack of action resulted in the facility not determining the underlying issues between the two residents or resolving the situation, contrary to facility policy and regulatory requirements.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
QAA Committee Failed to Identify and Address Systemic Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and implement corrective actions for several systemic issues affecting all 114 residents. Specifically, the QAA Committee did not recognize or address deficiencies in the infection control program related to mitigating the Covid-19 outbreak, failed to ensure that residents receiving dialysis were properly assessed before leaving for and after returning from outpatient dialysis, and did not ensure that all allegations of abuse were prevented, reported, and investigated. These failures were confirmed during an interview with the Administrator, who acknowledged that these systemic issues were not identified by the QAA Committee. A review of the facility's Quality Assurance Performance Improvement (QAPI) Plan indicated a commitment to proactively identifying and correcting quality issues, but the plan was not effectively implemented in practice. The lack of action by the QAA Committee resulted in the facility not meeting its stated goals of identifying concerns, discussing them openly, and developing plans to address them, as outlined in their QAPI policy.
Infection Control Lapses in PPE Use, Isolation, and Device Management
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed among staff caring for several residents. Certified Nursing Assistants and Restorative Nursing Aides failed to wear required isolation gowns while providing direct care to residents on Enhanced Barrier Precautions (EBP), including a resident with a Foley catheter and another with a gastrostomy tube. Staff members reported either not knowing about the EBP status due to missing signage or not following protocol, despite direct contact with residents. Additionally, a Licensed Vocational Nurse changed tube feeding for a resident on EBP without wearing a gown, and the required EBP signage was missing from the resident's door. Further deficiencies included improper management of a peripheral venous catheter, where a resident's catheter hub was left uncovered without a pressure cap, contrary to infection control protocols. Staff interviews confirmed awareness that a pressure cap was necessary to prevent infection. In another instance, multiple staff members, including CNAs and housekeeping, entered and exited a COVID-19 precaution room without donning all required PPE, such as gowns and eye protection, and failed to perform proper hand hygiene. Some staff also failed to change masks or sanitize hands upon leaving the room, despite facility policy requiring these measures for transmission-based precautions. Additional lapses were identified in the management of a resident diagnosed with scabies, where contact isolation was not implemented promptly after diagnosis and prescription of treatment. The facility delayed placing the resident on contact isolation, increasing the risk of transmission. Observations also revealed non-laundry items stored in the clean linen area, which was acknowledged by the Director of Nursing as inappropriate. Facility policies reviewed indicated clear requirements for PPE use, signage, and infection control measures, which were not consistently followed by staff.
Failure to Maintain Pest-Free Resident Environment
Penalty
Summary
A cockroach was observed crawling in a resident's room during a joint observation and interview with housekeeping staff, who confirmed having seen the bug before, noting it sometimes entered from the window or sink. The administrator later identified the bug as a cockroach and acknowledged it should not be present. The DON also confirmed that pests should not be inside resident rooms, as it does not provide a clean or safe environment. Review of the facility's pest control policy indicated that the facility is responsible for providing a clean environment and making all reasonable efforts to control pests. This deficiency was based on direct observation, staff interviews, and review of facility policy, demonstrating a failure to maintain a pest-free environment as required.
Failure to Ensure Resident Dignity and Respect in Personal Care and Hygiene
Penalty
Summary
The facility failed to ensure that multiple residents were treated with dignity and respect, as evidenced by several observed and documented deficiencies. One resident with an indwelling catheter did not have their catheter drainage bag concealed with a dignity bag, as confirmed by both observation and staff interview. Another resident, who required substantial assistance with personal care, was found wearing a hospital gown for an extended period against her preference and had unkempt hair due to a lack of grooming supplies and assistance. Staff confirmed the resident's appearance and the lack of grooming support. A third resident, with severe cognitive impairment and a colostomy, was observed with dirty teeth and had previously been documented as having soiled clothing due to an open colostomy bag, with feces noted on clothing on multiple occasions. Staff interviews corroborated that assistance with dental hygiene and personal cleanliness was not consistently provided. Additionally, the facility's own grievance records indicated repeated issues with soiled clothing and inadequate hygiene support for this resident. The facility's policy stated that residents should be treated with kindness, respect, and dignity, including being appropriately dressed and well-groomed. However, observations and interviews revealed that these standards were not met for several residents, resulting in undignified conditions such as visible medical devices, lack of grooming, and soiled clothing. These failures were acknowledged by facility leadership during interviews.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident was allowed to keep and self-administer multiple topical medications at her bedside without a physician's order and without an assessment to determine her capability to self-administer medications. The resident, who had a diagnosis of unspecified dementia but was assessed as having the capacity to understand and make decisions, was observed with several topical medications on her bedside table, including ammonium lactate lotion, triamcinolone acetonide cream, ketoconazole shampoo, and fluocinonide solution. The resident stated she used these medications for her dry, itchy skin and applied some of them herself. Interviews with nursing staff, including an LVN, RN, and the DON, confirmed that there was no documented assessment of the resident's ability to self-administer medications and no physician's order authorizing self-administration. Staff acknowledged that medications should not have been left at the bedside without proper assessment and orders, and that medications should have been stored in a locked treatment cart. The facility's policy required an interdisciplinary assessment and documentation in the chart before permitting self-administration of medications. Record review and staff interviews further revealed that the required procedures for evaluating and documenting the resident's ability to self-administer medications were not followed. The absence of a physician's order and lack of assessment documentation led to the resident having unsupervised access to her medications, contrary to facility policy and standard practice.
Failure to Ensure Call Lights Accessible for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible and within reach for two of four sampled residents, resulting in a delay of care and services. One resident, who had a history of urinary tract infection, cervical radiculopathy, and was assessed as a high fall risk with moderately impaired cognition, was observed lying in bed unable to reach the call light due to its placement at the top right corner of the bed, which was too high for her to access given her arm weakness. The resident stated she needed nursing assistance due to pain but could not reach the call light. A Certified Nursing Assistant confirmed the call light was out of reach and acknowledged it should have been clipped to the resident's gown or placed in her hand. Another resident, with diagnoses including encephalitis, encephalomyelitis, end stage renal disease, dependence on dialysis, dementia, and anxiety disorder, and with severely impaired cognition, was observed with the call light on the floor behind the bed, out of reach. A Registered Nurse confirmed the call light was not accessible and stated it should be within the resident's reach. The facility's policy required that call lights be within reach before staff leave the room, but this was not followed in these instances.
Failure to Address and Resolve Resident Grievance in a Timely Manner
Penalty
Summary
The facility failed to address, investigate, and resolve a grievance submitted by the family member of a resident with severe cognitive impairment and multiple medical conditions, including metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee. The grievance, filed regarding an unnamed CNA allegedly taking the resident's phone, closing the door on the resident, and turning the television volume up, was not acted upon or acknowledged for at least 54 days after submission. The Social Services Director, who was designated as the Grievance Official, was not made aware of the grievance at the time it was filed and only learned of it later through email correspondence. The facility's policy required the Grievance Official to be informed of all grievances to ensure timely follow-up and resolution. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that the grievance was not entered into the grievance log, nor was it investigated or resolved as required by facility policy. The policy stipulated that grievances should be acknowledged within three working days and that the Grievance Official was responsible for tracking, investigating, and resolving all concerns. The failure to follow these procedures resulted in the resident's grievance remaining unaddressed for an extended period.
Failure to Develop and Implement Comprehensive Care Plans for Residents with ROM Limitations and Edema
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the management of range of motion (ROM) limitations, post-fracture care, and edema. For one resident with a left humerus fracture and non-weight bearing status, the care plan did not address the resident's limited left shoulder ROM or the need for interventions to maintain or prevent decline in ROM after discharge from therapy services. Additionally, the care plan did not address the resident's repeated refusals to attend orthopedic follow-up appointments, nor was there documentation or notification to the physician or nursing staff regarding these refusals. The interdisciplinary team (IDT) failed to conduct required care conferences for the resident, missing quarterly meetings that would have facilitated updates to the care plan and communication among staff regarding the resident's ongoing needs and refusals. The case manager did not reschedule missed orthopedic appointments or document the reasons for missed appointments, and there was no evidence of physician notification. Interviews with staff confirmed that these omissions led to a lack of updated care planning and interventions for the resident's condition. For another resident with a history of deep vein thrombosis and ongoing right leg edema, the facility did not develop a care plan to address the edema, despite observations and staff acknowledgment of the condition. The absence of a care plan for edema was confirmed during interviews and record reviews, with staff stating that such a plan was necessary to monitor and guide care. The facility's policy required comprehensive, person-centered care plans for all residents, but this was not followed in these cases.
Failure to Provide Assistance with Grooming and Oral Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, with a history of major depressive disorder, difficulty walking, and rheumatoid arthritis, was observed wearing a hospital gown for two months and had unkempt, tangled hair. The resident expressed a preference for personal clothing and stated she did not have supplies to brush her hair. Staff confirmed that the resident required help with grooming and dressing, and that her hair was not groomed and she was wearing a hospital gown at the time of observation. Another resident, diagnosed with metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee, was observed with dirty teeth and reported not being assisted with toothbrushing that morning. Staff acknowledged that assistance with dental hygiene should have been provided. Documentation review revealed that this resident did not receive oral hygiene twice daily as required over a several-month period. The facility's policy indicated that residents unable to perform ADLs should receive necessary assistance, which was not followed in these cases.
Failure to Monitor Insulin Administration and Ensure Timely Orthopedic Follow-Up
Penalty
Summary
The facility failed to provide quality care and services for several residents by not adhering to physician orders, facility policies, and recommended follow-up care. For one resident with type 1 diabetes, end-stage renal disease, and dependence on hemodialysis, the facility did not monitor or document the resident's self-administration of insulin via an insulin pump as required by facility policy. There were multiple episodes where the resident's blood sugar was dangerously high, including one instance that required transfer to an acute care hospital for diabetic hyperglycemia. Nursing staff interviews revealed a lack of clarity regarding the resident's use of the insulin pump, with some staff stating the pump was not in use and others unaware of the resident's actual insulin administration method. Documentation of insulin administration was inconsistent, and the resident experienced both hyperglycemic and hypoglycemic episodes during the stay. Another resident with a left humerus fracture did not receive timely follow-up with orthopedic specialists as recommended by the consulting physician. Although an initial follow-up was scheduled, subsequent appointments were missed or refused by the resident, and these refusals were not documented or communicated to the physician or interdisciplinary team. The lack of follow-up led to prolonged non-weightbearing status on the affected arm, which was not reassessed for over eight months. Therapy staff and restorative aides were uncertain about the resident's care plan due to missing documentation and lack of updated orthopedic recommendations, resulting in a delay in progressing the resident's rehabilitation and care. Additionally, the facility failed to ensure that interdisciplinary team meetings were conducted quarterly for the resident with the humerus fracture, which would have facilitated communication about missed appointments and care plan updates. Staff interviews confirmed that the process for scheduling, documenting, and following up on physician-recommended appointments was not consistently followed. These deficiencies resulted in delays in care, lack of appropriate monitoring, and potential for further decline in residents' health and functional status.
Failure to Provide and Assess Range of Motion Services for a Resident with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate treatments and services to maintain or improve the range of motion (ROM) for a resident with a history of a left humerus fracture and limited left shoulder mobility. Despite a physician's order for physical and occupational therapy to provide ROM exercises to the resident's left shoulder and elbow, the facility did not ensure that these services were consistently provided. Occupational therapy was discontinued after a period of fluctuating participation, and no restorative nursing aide (RNA) services were initiated for the resident's left arm, even though the resident continued to have ROM limitations and required encouragement to use the left arm in daily activities. Joint Mobility Assessments (JMAs) conducted quarterly did not include an assessment of the resident's left shoulder, omitting a critical area of concern. Both the therapy department and the restorative nursing staff confirmed that the lack of assessment and absence of RNA orders for the left arm resulted in no interventions being implemented to address the resident's ongoing ROM limitations. Interviews with staff revealed that the resident would have benefitted from ROM exercises for the left arm, as she had limited mobility, pain, and required cueing to use the arm functionally. The facility's own policies required regular assessment and care planning for joint mobility, but these were not followed in this case. The Director of Rehabilitation and the Director of Nursing both acknowledged the importance of regular JMAs and the need for appropriate services when ROM limitations are identified. The resident herself reported not receiving assistance with arm exercises, and observations confirmed limited movement in the left arm. The failure to assess and provide services for the resident's left shoulder ROM was directly linked to the lack of follow-through on physician orders and internal protocols.
Failure to Monitor and Assess Catheterized Resident for UTI
Penalty
Summary
A deficiency was identified when a resident with a history of hydronephrosis and renal and ureteral calculous obstruction, who had an indwelling foley catheter, was not properly monitored or assessed for signs and symptoms of a urinary tract infection (UTI). The resident's care plan specifically required monitoring, recording, and reporting to the physician for symptoms such as pain, burning, blood-tinged urine, cloudiness, and foul-smelling urine. However, a review of the resident's medical records revealed no documentation of urine assessment or monitoring for infection. Interviews with facility staff, including an LVN and the DON, confirmed that there was an expectation for residents with foley catheters to be monitored for infection, but this was not carried out or documented for this resident. The facility's policies and job descriptions also supported the need for such assessments, but the required monitoring was not performed, resulting in a failure to follow established protocols for catheter care and infection prevention.
Failure to Provide Safe and Appropriate Dialysis Care and Services
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for several residents requiring hemodialysis, resulting in multiple deficiencies. One resident with end stage renal disease and dependence on dialysis did not receive hemodialysis as scheduled, missing a session and subsequently experiencing facial swelling. This resident required admission to an acute care hospital and was diagnosed with fluid overload due to the missed dialysis session. Documentation and interviews confirmed that the resident's dialysis schedule was not maintained, and there was no evidence that the physician was contacted to reschedule the missed session. Another resident with a Permacath for dialysis was observed without a dressing covering the catheter site, contrary to physician orders and facility policy. The absence of a dressing was confirmed by a registered nurse, who acknowledged that a dressing should have been present to prevent infection. Additionally, a third resident was not assessed by facility staff prior to being sent to dialysis or upon return from the dialysis center, as required by facility policy. The pre- and post-dialysis assessment forms were found to be incomplete for multiple dialysis days, indicating a lack of monitoring for potential complications related to dialysis therapy. A fourth resident, who had an arteriovenous shunt for dialysis, did not have the necessary emergency equipment (e-kit) at the bedside to manage potential bleeding emergencies. Nursing staff were unaware of the location of the e-kit, and acknowledged that the absence of this equipment could hinder immediate intervention in the event of shunt dislodgement or bleeding. Facility policy required ongoing communication, assessment, and documentation for residents receiving dialysis, including the presence of emergency supplies and proper site care, all of which were not consistently followed.
Failure to Ensure Staff Competency in Locating PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Restorative Nursing Aide 1 and Restorative Nursing Aide 2 were found to lack competency in locating personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) due to a physician's order related to a urinary tract infection and the presence of a Foley catheter. During a restorative nursing session, both aides entered the resident's room, donned gloves, but did not wear isolation gowns as required for EBP. They assisted the resident with range of motion exercises and, upon completion, removed their gloves, washed their hands, and exited the room. Both aides later stated they were unaware the resident was on EBP precautions, did not see the precaution signage, and did not know where to find the required PPE since it was not in the usual location outside the room. A review of the aides' competency checklists revealed that training on the location of PPE for residents on EBP precautions was not included. The Infection Prevention Nurse confirmed that PPE for EBP residents was now stored inside the resident's closet, a change from previous practice, and acknowledged there was no documented evidence that the aides had been in-serviced on this change. The Director of Nursing also emphasized the importance of staff competency in infection control protocols and PPE location. Facility policy required nursing staff to have appropriate competencies to ensure resident safety and well-being.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.54% during medication administration for two of four sampled residents. For one resident, the nurse did not administer vitamin B1 as ordered and provided an incorrect dose of vitamin B12, giving only 500 mcg instead of the prescribed 1000 mcg. The nurse prepared and administered multiple medications but omitted vitamin B1 and did not ensure the correct dosage of vitamin B12, despite the physician's orders and the medication bottles available. The nurse later acknowledged the omission and the importance of following physician orders to prevent medication errors. For another resident, the nurse failed to clarify the physician's order for MiraLAX (polyethylene glycol) before administration and did not follow the medication label and manufacturer specifications. The nurse mixed the MiraLAX powder with an incorrect volume of water, initially believing the facility's water cup held eight ounces, but later confirming it only held five ounces. The pharmacy label specified mixing the powder with eight ounces of water, but the physician's order did not specify the volume. The nurse did not measure the water accurately during administration and did not clarify the order to ensure it matched the pharmacy label, which could have affected the medication's effectiveness. Interviews with nursing staff and the Director of Nursing confirmed that medications were not administered in accordance with physician orders, manufacturer instructions, and facility policy. The facility's policy required medications to be administered as prescribed and in accordance with manufacturer specifications, but this was not followed in the observed cases. The deficiencies were identified through observation, interview, and record review, and were directly related to the actions and inactions of the nursing staff during medication administration.
Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to administer medications as ordered for two residents. One resident, with diagnoses including encephalitis, end stage renal disease, dementia, and anxiety disorder, was prescribed Eliquis 2.5 mg twice daily for atrial fibrillation. Review of the Medication Administration Record (MAR) revealed that Eliquis was not administered as ordered on several occasions in February and March, specifically on days when the resident went to dialysis. The Assistant Director of Nursing acknowledged that the administration times should have been clarified with the physician for those days, but this was not done, resulting in missed doses. Another resident, with diagnoses including metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee, was prescribed Levothyroxine Sodium Oral Tablet 88 mcg to be given once daily in the morning. The MAR showed that this medication was not administered from 9/13/2024 to 9/18/2025, despite the order. The Licensed Vocational Nurse confirmed the medication should have been given to maintain normal thyroid levels. The facility's policy and procedure required medications to be administered as prescribed, but this was not followed in these cases.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices. In two of three medication carts, medications were not stored according to the facility's policy and professional standards. Specifically, a vial of atropine sulfate ophthalmic solution intended for sublingual use was stored in the same bin as acetaminophen rectal suppositories, contrary to the policy requiring separation of oral, ophthalmic, and rectal medications. Additionally, an unopened bottle of latanoprost ophthalmic solution was found without an open date label and was not stored in the refrigerator as required by the manufacturer's instructions. Staff interviews confirmed that these storage practices were not in line with facility policy or manufacturer requirements, and that proper labeling was necessary to ensure medication safety and efficacy. Further deficiencies were observed in the medication room refrigerators. In one refrigerator, several medications, including insulin, Tubersol, acetylcysteine, and Dupixent, were stored at 35°F, which is below the manufacturer-recommended range of 36°F to 46°F. The refrigerator also had a buildup of ice, which is not appropriate for medication storage. Staff acknowledged that these conditions could compromise the integrity of the medications. In another medication room refrigerator, a bottle of prednisolone acetate ophthalmic suspension was stored in the refrigerator, despite manufacturer instructions to store it at room temperature and protect it from freezing. Staff confirmed that this was not the correct storage method and could affect the medication's effectiveness. The facility's policy and procedure on medication storage requires that medications and biologicals be stored according to manufacturer recommendations and that internally administered medications be kept separate from externally used medications. Staff interviews consistently indicated awareness of these requirements, but observations revealed that these standards were not consistently followed. The deficiencies involved multiple residents and had the potential to affect the safety and effectiveness of their prescribed medications.
Failure to Dispose of Expired Food and Improper Labeling of Resident Food
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of expired food items and did not adhere to labeling and storage policies for resident food. Specifically, Italian salad dressing and barbeque sauce were found in the refrigerator past their best by dates, and caramel sauce was stored beyond the recommended use period after opening. Both the cook and the dietary supervisor confirmed during interviews that expired food should not be stored and acknowledged the risk of illness if residents consume expired items. Additionally, four bottles of coffee creamer and a peanut butter sandwich in the resident food refrigerator were not labeled with the resident's name, date, or room number as required by facility policy. The peanut butter sandwich was labeled with a staff member's name, which is not permitted. Interviews with a CNA and the DON confirmed that only resident food, properly labeled, should be stored in the designated refrigerator, and that improper labeling makes it unclear how long food has been stored, increasing the risk of serving expired food to residents. Review of facility policies corroborated these requirements for food storage and labeling.
Failure to Accurately Document and Maintain Accessible Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation and accessibility of medical records for one resident, resulting in two specific deficiencies. First, the Joint Mobility Assessment (JMA) for the resident, who had a history of a left humerus fracture and subsequent surgical repair, was not accurately completed. Although the resident had been cleared for range of motion (ROM) exercises by a physician, the JMA did not indicate the severity of ROM loss in the left shoulder, and the therapist failed to update the diagram or document the level of severity. The therapist acknowledged that the assessment was inaccurate and that the omission could prevent proper monitoring of changes in the resident's ROM status. Second, the facility did not ensure that the resident's Orthopedic Consultation Progress Note from a follow-up appointment was readily accessible in the medical record. Despite orders and progress notes referencing the orthopedic follow-up, staff were unable to locate the consultation note in either the physical chart or the electronic record. Both the Director of Rehabilitation and the Medical Records staff confirmed the absence of this critical document, which contained recommendations and the plan of care for the resident's post-surgical management. The resident involved was admitted with a displaced fracture of the left humerus and required ongoing rehabilitation and post-operative care, including non-weight bearing restrictions and therapy interventions. The lack of accurate assessment documentation and the missing orthopedic consultation note had the potential to delay or negatively affect the delivery of necessary care and services, as staff were not fully informed of the resident's current status or care plan.
Failure to Document McGeer's Criteria for Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy for two of three sampled residents by not completing the required McGeer's Criteria documentation when antibiotics were prescribed. For one resident admitted with cellulitis and bacteremia, the physician ordered intravenous Ceftriaxone, but the Infection Surveillance form lacked documentation indicating whether the antibiotic order met McGeer's Criteria, with relevant sections left blank. Similarly, another resident admitted with sepsis and bacteremia received an order for intravenous Ceftriaxone for GBS Bacteremia, but again, the Infection Surveillance form did not document if McGeer's Criteria were met, with blank spaces in the appropriate sections. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON) revealed that the IPN did not verify if the antibiotic orders from the hospital met McGeer's Criteria, contrary to facility policy. The DON confirmed that McGeer's Criteria should be considered when verifying antibiotic orders, as outlined in the facility's antibiotic stewardship policy. The policy requires the stewardship team to optimize diagnostic testing and implement an antibiotic review process for all antibiotics prescribed in the facility.
Failure to Document and Administer Influenza and Pneumonia Vaccinations
Penalty
Summary
The facility failed to document education provided regarding the benefits and risks of influenza and pneumonia vaccinations, as well as the administration of these vaccines, for three of 21 sampled residents. For one resident, although a consent form for the pneumococcal vaccine was signed by the resident's daughter, there was no documentation that the vaccine was actually administered. Another resident's records did not contain any consent forms for influenza or pneumonia vaccines, and there was no evidence that these vaccines were offered. A third resident's care plan referenced keeping immunizations up to date, but there was no documentation of education, consent, or administration of the vaccines. Interviews with the Infection Preventionist Nurse revealed that, while the process is to offer and educate residents or their families about the risks and benefits of the vaccines and obtain signed consent forms, there was no documented evidence of vaccination, refusal, or education for the residents in question. The Infection Preventionist Nurse also stated that if there is no way to track vaccinations, residents may miss their vaccinations. The Director of Nursing confirmed that all residents should be offered influenza and pneumonia vaccines, and that documentation of acceptance or refusal is necessary, but acknowledged that this was not done for the residents identified. A review of the facility's policies and procedures indicated that it is the facility's policy to offer and administer influenza, pneumococcal, and COVID-19 immunizations to eligible residents after providing education and obtaining consent. Residents are to be screened at admission and annually for vaccine eligibility. However, the lack of documentation and tracking for the sampled residents demonstrates that these policies and procedures were not followed, resulting in a failure to ensure proper vaccination practices.
Failure to Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to document education provided regarding the benefits and risks of COVID-19 immunization and the administration of the vaccine for two of three sampled residents. For one resident with dementia and aphasia, who was dependent on staff for most activities of daily living, there was no documentation of education or vaccination status. Another resident, who had moderate cognitive impairment and required substantial assistance, was not given the COVID-19 vaccine because the resident's daughter requested it be given later; however, there was no documentation of this request or the reason for not administering the vaccine. The Infection Preventionist Nurse acknowledged not documenting the family's request or ordering the vaccine, and the Director of Nursing confirmed that vaccines should be ordered and administered promptly upon request. A review of facility policy indicated that residents are to be offered and administered immunizations, including COVID-19, after education and consent are obtained, and that documentation of education and consent is required. The lack of documentation for both the education provided and the reasons for not administering the vaccine to eligible residents represents a failure to follow facility policy and proper immunization procedures.
Failure to Protect Resident from Abuse and Inadequate Response to Allegations
Penalty
Summary
The facility failed to protect a resident from abuse in multiple instances involving both another resident and a staff member. One incident involved a resident with severe cognitive impairment who was found in another resident's room wearing only a hospital gown and disposable underwear, and kissed the resident's arm without consent. This event was witnessed by a family member and later confirmed by the resident, who reported that the other resident held her hand, kissed her arm, and sat in her room without pants. Staff interviews revealed that the incident was not immediately reported to the appropriate administrative personnel, and the affected resident was not assessed, monitored, or provided with emotional support following the allegation of abuse. A separate incident involved a grievance filed by a family member alleging that an unidentified CNA took the resident's cell phone, closed the door, and turned the television on loud, resulting in the resident feeling isolated. This grievance was not immediately addressed or resolved, and the resident was not assessed or monitored for psychosocial well-being after the allegation. Staff interviews confirmed that the required follow-up actions, such as interviewing involved staff and ensuring the resident's stability, were not performed. The facility's own policy requires immediate assessment, increased supervision, emotional support, and reporting of abuse allegations, but these procedures were not followed in either incident. The failures resulted in the resident being subjected to a nonconsensual kiss, isolation, and a lack of appropriate response to abuse allegations, as documented by interviews with staff and review of facility records.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Norwalk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Intercommunity Healthcare & Rehabilitation Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Norwalk Skilled Nursing & Wellness Centre, Llc | 0.9 mi | ★★★★★ | 4 | 0 |
| Studebaker Healthcare Center | 1.1 mi | ★★★★★ | 46 | 0 |
| The Springs Post-acute | 1.6 mi | ★★★★★ | 31 | 0 |
| Lakewood Healthcare Center | 1.7 mi | ★★★★★ | 45 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.