Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. John Of God Retirement during CMS and state inspections, most recent first.
A resident with depression and congestive heart failure was started on Cymbalta 30 mg daily following a physician telephone order, and the MAR showed the medication was administered over several weeks. The resident was documented as cognitively capable of decision making and had a designated representative, yet there was no documentation that informed consent for the psychotropic medication was obtained from the representative. During interviews, the ADON and DON acknowledged that psychotropic drugs should not be initiated without informed consent and that this omission violated resident rights. Facility policy required staff and the physician to review non-pharmacological options, indications, risks, benefits, and the right to accept or decline treatment with the resident or representative before obtaining documented consent or refusal, but this process was not documented for this resident.
A resident with dementia, severe cognitive impairment, a fall history, and physician orders for daily wheelchair and bed alarms had consistent alarm use documented on the MAR, but the corresponding MDS did not code daily use of these alarms. The MDS nurse later confirmed that, based on the 7-day lookback period, alarms were used every day and that the assessment was not accurate, contrary to the job requirement that MDS assessments accurately reflect the resident’s condition and care.
A resident with severe cognitive impairment, poor safety awareness, and a history of multiple unwitnessed falls at the bedside was assessed as high risk for falls and had a physician order and IDT recommendation for floor mats on both sides of the bed. On observation, no floor mats were present, and a CNA reported routinely removing the mat during the day and being unsure if it was replaced later. One LVN was unaware of any floor mat orders and could not recall recent use of mats, while another LVN confirmed the order and his responsibility to carry it out but had not verified mat placement that morning. Staff acknowledged that the use of floor mats was not included in the resident’s care plan, despite facility policy requiring care plans to guide daily care and be available to all staff.
Two residents with severe cognitive impairment and known fall risks did not receive consistent implementation of ordered fall-prevention measures, including floor mats and bed/wheelchair alarms, and one did not receive a required post-fall risk evaluation. For one resident, surveyors found that ordered floor mats were not in place at the bedside, alarms ordered after prior falls were not in use, and staff had not timely documented or reported the resident’s ongoing removal of alarms to the physician, despite care plan and policy requirements. For the other resident, staff did not complete a Fall Risk Evaluation after an unwitnessed fall with reported knee pain, contrary to facility policy and the ADON’s stated expectations for immediate or 24-hour post-fall assessment.
Improper food labeling and expired sanitizer test strips were observed in the kitchen. In two refrigerators, multiple food items were unlabeled, undated, or had illegible or expired use-by dates, including salad dressing, mustard sauce, and chocolate syrup. The DFS also used an expired chlorine test strip to check dishwasher sanitation strength after a tray was sanitized.
The facility failed to document competency assessments for four CNA/RNA staff members. The DSD did not have competency checked off as demonstrated for weighing residents for three CNAs and for providing ROM exercises for one RNA. The DSD and DON stated that staff competency is important because it reflects resident care and that missing competencies could lead to errors in care.
A facility failed to keep accurate narcotic records for two residents and failed to obtain two signatures on a narcotic destruction log for another resident. During cart checks, morphine bottle amounts did not match the documented counts, and staff including the LVN, RN, and DON acknowledged the discrepancies. The destruction record for an unused narcotic after discharge had only one signature, despite the DON stating both the DON and pharmacist were responsible for signing.
An opened tuberculin vial, an opened box of Omeprazole, two opened boxes of Tamiflu, and an opened box of anti-diarrheal medication were found without open dates in multiple med storage areas, despite facility policy requiring the open date to be recorded on multidose containers. An opened Acidophilus bottle was also left unrefrigerated in a med cart even though the label indicated it should be refrigerated after opening.
Staff failed to perform hand hygiene before touching two residents, and a resident’s g-tube was observed uncapped and exposed to open air when not in use. One resident had severe cognitive impairment and dependence on staff, while the other had multiple serious diagnoses including a stage 4 pressure ulcer, dysphagia, and DM. The CNA, RNS, DON, and LVN all acknowledged the importance of hand hygiene and capping feeding tubing, and the facility policy required hand hygiene before and after resident contact.
Resident room temperatures were not maintained within the required range for two residents. One resident with dementia and another cognitively intact resident both reported their rooms were cold, and observations showed thermostats in the high 60s while the MM later measured temperatures of 66.2 F and 64.9 F. The MM and MS stated resident room temperatures should be maintained between 71 F and 80 F, consistent with facility policy.
MDS assessments for two residents were inaccurate because Gabapentin was not coded as an anticonvulsant in Section N0415. One resident had GT feeding, stroke history, DM, and severe cognitive impairment, while the other had DM, COPD, HTN, intact cognition, and needed assistance with ADLs. Both residents had active Gabapentin orders, and the MDS nurses stated the medication should have been coded according to its therapeutic class.
Failure to develop a comprehensive person-centered care plan for antifungal medication. A resident with UTI, CVA, and DM, who lacked decision-making capacity and was dependent for personal care, received fluconazole for a yeast infection. The MDS nurse confirmed there was no care plan for the medication, and stated a care plan is needed to monitor side effects and black box warnings; the ADON stated care plans help staff understand individualized needs.
A resident with Alzheimer’s disease, anxiety, adult failure to thrive, and osteoporosis had a care plan for bed and wheelchair alarms, but staff did not revise it when her condition changed. She was assessed as severely cognitively impaired and dependent for most ADLs, yet was observed in a wheelchair and in bed without an alarm. A CNA stated the resident did not need an alarm because she was contracted and unable to get up on her own, while an RNS said nurses are supposed to update care plans as needed.
A facility failed to ensure correct low air loss mattress settings for two residents with pressure ulcers. One resident with a stage 4 PU, DM, dysphagia, and severe cognitive impairment was observed on a mattress set at 350 lbs despite weighing 129 lbs. Another resident with a stage 3 sacral PU, DM, PVD, and necrosis of an amputation stump was observed on a mattress set at 225 lbs despite weighing 150 lbs. Staff stated the settings were incorrect and that the mattress setting is based on resident weight.
Failure to Provide Ordered 1:1 Supervision: A resident with dementia, severe cognitive impairment, and dependence for ADLs was care planned for continuous 1:1 monitoring due to poor safety awareness. During observation, the resident was in bed with floor mats in place, but no staff member was present at the bedside. CNA stated that continuous monitoring required staff to be with the resident at all times and confirmed the resident was not being monitored as ordered.
Failure to provide bladder training for a resident with urinary incontinence. A resident with intact cognition, who required supervision with toileting hygiene and was frequently incontinent of urine, had no documented trial of scheduled toileting, prompted voiding, or bladder training. The MDS nurse confirmed there was no evidence the toileting program was implemented, and the ADON stated such a program was important for the resident’s dignity.
A resident with chronic respiratory failure with hypoxia, emphysema, and cerebral ischemia was ordered continuous O2 at 2 L/min and had a care plan focused on maintaining a clear airway. During observation, the resident’s oxygen tubing was found kinked at the humidifier port. Staff interviews confirmed that kinks in oxygen tubing should be reported and can lower O2 saturation, and the facility policy required oxygen tubing to be checked for kinks.
Failure to assess pain for a resident with dementia and CKD. The resident had an order for PRN acetaminophen for mild pain, was observed frowning, and stated he had pain in his right forearm. A CNA reported the resident had complained of pain, but the RN said no pain assessment had been completed or documented before later assessing the resident and identifying mild pain.
A resident with chronic respiratory failure, obesity, dementia, and diabetes had bowel incontinence documented on the MDS and daily BM logs showing a BM every day, but weekly nursing assessments contained conflicting entries about the last BM. The ADON acknowledged the discrepancies in the assessments and stated the documentation should be accurate and reflect the correct information.
Missing Hospice Visit Calendar: A resident on hospice with COPD, prior stroke, dysphagia, and severely impaired cognitive skills had no hospice calendar available showing scheduled hospice team visits. An LVN stated the calendar was used to coordinate hospice services, and the ADON stated it supported collaboration between the facility IDT and hospice team for continuity of care.
A resident with hemiplegia, hemiparesis, aphasia, left-sided weakness, and severe cognitive impairment was observed sitting in a wheelchair and unable to reach the call bell, which was placed under a pillow on the bed. CNA and RNS staff stated the resident could not reach the call light or verbally request help, and the DON stated the call bell is an important means of communication between staff and residents. The facility policy required the call light to be accessible from bed, the toilet, the shower or bathing area, and the floor.
Unattended Cigarettes Left in Designated Smoking Area: Surveyors observed a pack of cigarettes left unattended inside a crocheted pouch on a wooden bench in the designated smoking area behind the chapel. The DON stated residents are not allowed to keep cigarettes or lighters, that cigarettes are stored in a locked area, and that the smoking area is supervised for safety. The DON later stated it was unacceptable for cigarettes to be left unattended, while the AA said cigarettes are supposed to be locked in the activities room drawer.
Incomplete Facility Assessment Missing Contingency Plan: The facility failed to include a contingency plan in its Facility Assessment. During interview and record review, the ADM stated the assessment was incomplete and did not address staffing needs or a plan of action for staffing shortages during an emergency. The facility P&P stated the annual assessment is used to determine resources needed for competent resident care during day-to-day operations and emergencies, including contingency planning for staffing availability.
The facility failed to ensure the IPN attended, participated in, and reported findings to the QAA committee on a regular basis. The ADM stated the IPN did not attend or take part in QAA/QAPI meetings and that quarterly participation was required to discuss infection control issues and updated state and federal regulations. The facility’s QAPI plan listed the IPN as a required committee member and stated the committee meets at least quarterly.
A resident with severe cognitive impairment was found with a bump and discoloration on the back of the head, but staff did not report the injury of unknown origin to CDPH within the required two-hour timeframe. The delay in reporting was confirmed through staff interviews and record review, resulting in a delayed investigation and potential risk to all residents.
A resident with multiple complex diagnoses, including atrial fibrillation and dementia, was administered heparin injections without a comprehensive care plan in place to address the medication and its associated risks. Despite physician orders and facility policy requiring such a plan, the care team did not initiate or document interventions or monitoring for potential complications, as confirmed by the DON.
Expired food items, including baking soda, colander seeds, red food coloring, and breadcrumbs, were found in the facility's dry storage room. The Dietary Procurement Personnel and Dietary Manager acknowledged the importance of labeling and discarding expired items to prevent potential illness among residents. The facility's policy requires proper storage and labeling, but these procedures were not followed.
The facility failed to follow infection control practices by washing laundry at incorrect temperatures, storing resident cold packs with staff food, and improperly disinfecting a cloth gait belt. Staff were unaware of the correct laundry temperature policy, and resident equipment was stored with staff food, risking contamination. A cloth gait belt was inadequately disinfected with wipes, contrary to facility policy requiring proper cleaning of reusable items.
The facility did not post the results of complaint investigations by the CDPH in accessible areas, violating residents' rights. The DON acknowledged the survey binder was incomplete, and the ADM confirmed the responsibility to post these results. Facility policies stated residents' rights to access survey results, but the facility failed to comply.
The facility failed to conduct annual competency assessments for an LVN and three CNAs, as required by policy. The DON, recently hired, had not completed these assessments, which are necessary to ensure staff can safely perform their duties. This oversight was confirmed through record reviews and interviews.
The facility failed to label opened medications with the date in two medication carts, risking the administration of expired drugs to residents with conditions like epilepsy and diabetes. LVNs acknowledged the risk, and the DON stressed the importance of proper labeling per policy.
A resident with severe cognitive impairment was not dressed daily, remaining in a hospital gown over several days, contrary to their care plan and the facility's dignity policy. Staff interviews confirmed the resident was only dressed when taken out of bed, highlighting a failure to promote the resident's dignity and self-esteem.
A resident with multiple medical conditions, including a fractured femur and dementia, was found with the call light out of reach, potentially delaying necessary care. A CNA confirmed the oversight and corrected it, while the DON acknowledged the importance of call light accessibility as per facility policy.
The facility failed to notify the physician of significant changes in two residents' conditions. One resident experienced an 18-pound weight loss over three months without physician notification, despite facility policy requiring it. Another resident had swollen ankles, a new finding, but the physician was not informed. These oversights placed the residents at risk for further complications.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect data being sent to CMS. One resident's schizophrenia diagnosis was not reflected in the MDS, and another resident's MDS was not updated quarterly. The MDS Nurse and DON acknowledged these deficiencies, emphasizing the importance of timely and accurate assessments for resident care and facility reimbursement.
A facility failed to accurately complete the PASRR Level 1 screening for a resident with schizophrenia, leading to the omission of a necessary Level 2 evaluation. The resident, who had a history of schizophrenia and dementia, was incorrectly documented as having no serious mental illness, resulting in the case being closed without further evaluation. This oversight was identified during a review of the resident's records, where it was noted that the facility did not adhere to its policy of completing a new PASRR when a new mental health disorder was diagnosed.
The facility failed to create individualized care plans for three residents, leading to unmet care needs. A resident with a history of falls lacked a care plan for a one-to-one sitter. Another resident experienced significant weight loss without a care plan for nutritional interventions. A third resident had swollen ankles without a care plan to address the condition. The facility's policy requires comprehensive care plans, but this was not followed.
A resident with severe cognitive impairment and specific preferences for outdoor activities was not taken outside for garden strolls, despite it being important for their well-being. Facility staff confirmed the lack of a schedule for such activities, and the Director of Nursing acknowledged the oversight, which contradicted the facility's policy on individualized care and meaningful engagement.
A resident with a pacemaker was not monitored according to professional standards, as their pacemaker had not been checked for four years. Despite the care plan requiring regular evaluations, a scheduled check was canceled and not rescheduled. The facility's policy required checks every three months or yearly, depending on the model, to prevent potential malfunctions.
The facility failed to conduct timely joint mobility assessments for three residents with limited ROM, as required by their care plans. Residents with conditions such as dementia, cerebral infarction, and osteoarthritis did not receive quarterly assessments on time, potentially affecting their physical capabilities. The ADOR and DON acknowledged the importance of timely assessments to monitor and address any decline in ROM.
A facility failed to provide floor mats for a resident at high risk of falls, despite the care plan indicating their necessity. The resident, with severe cognitive impairment and multiple diagnoses, was observed without floor mats on two occasions. Additionally, the facility did not replace sharps containers in several rooms when they were over 75% full, contrary to policy, posing a risk of needlestick injuries. Staff interviews confirmed these deficiencies.
A facility failed to follow its policy for maintaining oxygen therapy equipment for a resident, leading to undated and unlabeled oxygen tubing and humidifier. The resident, with acute respiratory failure and obstructive sleep apnea, had an order for BIPAP therapy. An LVN confirmed the oversight, acknowledging the risk of bacterial growth and infection. The DON highlighted the importance of weekly changes for infection control and proper oxygen delivery.
A facility failed to obtain a physician's order for a 1:1 sitter for a resident with a history of falls and cognitive impairment. Despite the resident's need for close supervision due to muscle weakness, lack of coordination, and dementia, the required order was not found in the medical chart, contrary to the facility's policy.
A resident with severe cognitive impairment and functional limitations did not receive physical therapy (PT) services despite an active physician's order. The order for PT evaluation and treatment was not executed, and no documentation explained the omission. The Assistant Director of Rehabilitation and the Director of Nursing confirmed the oversight, noting that the rehabilitation department should have acted on the order within 24 hours.
A facility failed to maintain timely medical records for a resident when their Joint Mobility Assessment (JMA) was not documented until nearly a year after the effective date. The resident, with diagnoses including Parkinson's Disease and cerebral infarction, was assessed as cognitively intact with functional limitations. The delay was confirmed by the Assistant Director of Rehabilitation, who noted the JMA was signed late, not meeting professional standards. The Director of Nursing highlighted the importance of timely documentation for continuity of care.
A resident's representative signed an arbitration agreement without understanding its implications due to a lack of explanation from the facility. The Admissions Coordinator did not discuss the agreement with the representative, and the facility lacked a specific arbitration policy, leading to the deficiency.
A facility failed to ensure hospice services met professional standards for a resident with Alzheimer's and hypertension. The hospice representative did not participate in care conferences, and the facility lacked a hospice calendar and updated physician certification, leading to a lapse in hospice care coordination.
The facility did not update and post daily staffing information as required. Observations revealed that the Direct Care Service Hours Per Patient Day (DHPPD) forms at the front desk and a nursing station were outdated by several days. A CNA confirmed the lack of updates, and the DSD acknowledged the oversight, noting that updates should occur daily, including weekends and holidays, as per facility policy.
A facility failed to elevate a resident's head of bed to the required 30 to 45 degrees during gastrostomy tube feeding, as ordered by the physician. The resident, with a history of dysphagia and respiratory failure, was observed with the bed elevated only to 20 degrees, contrary to the care plan and facility policy, increasing the risk of aspiration.
A facility failed to inform a resident's responsible party about skin discoloration, an x-ray order, and its results, violating their policy. The resident had severe cognitive impairment and required extensive assistance. The oversight was acknowledged by an LVN during an interview.
Failure to Obtain Informed Consent Prior to Initiation of Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident representative prior to initiating a psychotropic medication. A resident with diagnoses including depression, knee surgery, and congestive heart failure was initially admitted and later readmitted to the facility. A History and Physical dated 9/12/2025 documented that the resident had the capacity to understand and make decisions, and a Minimum Data Set dated 1/7/2026 indicated the resident was independent in cognitive skills for daily decision making, though requiring moderate assistance with some activities of daily living. On 2/2/2026, a physician placed a telephone order for Cymbalta 30 mg by mouth in the morning for depression, and the Medication Administration Record showed the resident received this medication daily from 2/4/2026 to 2/24/2026. During an interview and concurrent record review on 2/24/2026, the ADON confirmed there was no documentation in the clinical record indicating that informed consent for Cymbalta had been obtained from the resident’s representative, despite the admission record identifying that the resident had a representative. The ADON stated that facility staff cannot initiate any psychotropic drug until the physician obtains informed consent from the resident’s representative and acknowledged that no such consent was present in the chart. The DON stated that not obtaining informed consent prior to initiating any psychotropic drug is a violation of resident rights and that residents or their representatives have the right to make an informed decision to accept or decline psychotropic medications. Review of the facility’s policy on Psychotropic Medication Use, dated 3/2025, showed that prior to initiating, increasing, or switching psychotropic medications, staff and the physician are required to review non-pharmacological interventions, indications and rationale, potential risks and benefits, and the right to accept or decline treatment with the resident or representative before obtaining documented consent or refusal.
Inaccurate MDS Coding for Daily Use of Alarms
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, resulting in the transmission of inaccurate clinical data to CMS. The resident had dementia, a history of falls, and severe cognitive impairment, and required partial to moderate staff assistance for transfers. A physician order dated 4/30/2024 directed staff to apply both a wheelchair and bed alarm to alert staff when the resident attempted to get up without assistance. The Medication Administration Record for the entire month of December 2025 documented daily use of both a wheelchair and bed alarm for this resident. Despite this, the MDS dated [DATE] did not indicate the resident’s daily use of a bed or wheelchair alarm. During interview, the MDS Assistant stated that MDS coding for alarms is based on the previous seven days of alarm use and confirmed that the resident had used alarms daily during that seven-day lookback period. The MDS Assistant acknowledged that the MDS dated [DATE] was not accurate and stated that the MDS should accurately reflect the resident’s clinical condition and the care they received or required, and that alarms were considered a restraint whose use should be routinely reviewed. The facility’s MDS Coordinator Lead job description required that resident assessments present an accurate reflection of the resident, which was not met in this case.
Failure to Care Plan and Implement Ordered Floor Mats for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan that reflected a physician’s order for floor mats for a resident at high risk for falls. The resident had diagnoses including cognitive impairment and lack of coordination, and assessments documented severe cognitive impairment, inability to make decisions, and a need for substantial to maximal assistance with bed mobility and transfers. Following an unwitnessed fall on 8/11/2025, a Change of Condition assessment and Fall Risk Evaluation identified the resident as high risk for falls. A physician order dated 8/11/2025 directed that floor mats be placed on either side of the resident’s bed, and an IDT review on 8/12/2025 recommended floor mats at the bedside to reduce injury risk. Subsequent Change of Condition assessments on 8/18/2025 and 12/17/2025 documented two additional unwitnessed falls at the bedside. On observation on 1/15/2026, no floor mats were present on either side of the resident’s bed. A CNA reported that the resident was at risk for falls due to a history of falls and frequent attempts to get out of bed unassisted, and stated she usually removed the floor mat during the day shift and was unsure if staff replaced it in the evening. One LVN stated the resident had a history of falls and attempts to get out of bed unassisted, could not recall recent use of floor mats, and was not aware of any floor mat orders, adding that floor mats should be care planned so all staff would know they were needed. Another LVN confirmed the resident had orders for floor mats on either side of the bed and that he was responsible for ensuring physician orders were carried out, but he did not recall checking for floor mats that morning and acknowledged there was no care plan for floor mat use. The facility’s care plan policy stated that the care plan was to be used in developing the resident’s daily care routines and be available to staff responsible for providing care or services.
Failure to Implement Ordered Fall-Prevention Measures and Complete Post-Fall Risk Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain ordered fall-prevention interventions and to complete required fall risk evaluations for residents identified as being at high risk for falls. One resident with severe cognitive impairment, poor safety awareness, and a documented history of unwitnessed falls had physician orders and IDT recommendations for floor mats to be placed on both sides of the bed following a fall. Despite these orders and the facility’s fall management policy, surveyors observed that no floor mats were at the bedside; instead, a single fall mat was stored behind the room door. A CNA reported that only one mat was used and that she typically removed it during the day shift, and an LVN stated he was unaware of any floor mat orders and had not ensured their implementation, even though the LVN job description required carrying out physician orders. The same resident had additional physician orders for a bed alarm and wheelchair alarm after another unwitnessed fall, and the care plan directed staff to monitor, document, and report changes in the effectiveness of these alarms. Multiple subsequent assessments, including a change of condition assessment and a rehab post-fall screen, documented that alarms and floor mats were not in place at the time of later falls and that the resident continued to exhibit confusion, impulsiveness, forgetfulness, and poor safety awareness. Staff interviews revealed that CNAs and LVNs had not observed the resident using bed or wheelchair alarms, and one LVN acknowledged that the resident had a known pattern of removing and dismantling alarms, but this behavior had not been documented or reported to the physician until months later. The ADON stated that the physician should be notified when a resident refuses ordered alarms so that the plan of care can be reviewed and other interventions considered, and the facility’s fall protocol required staff to monitor and document resident responses to fall interventions. A second resident, also with severe cognitive impairment and requiring supervision or touch assistance for bed mobility and transfers, experienced an unwitnessed fall in the dining room, after which she complained of right knee pain. Although the facility’s fall clinical protocol required staff to re-evaluate the situation and reconsider fall interventions after any fall, and the ADON stated that a Fall Risk Evaluation should be completed immediately or within 24 hours following any fall, no Fall Risk Evaluation was completed for this resident after the incident. The ADON confirmed that the assessment was not done and acknowledged that it should have been completed to promptly identify interventions to prevent further falls.
Improper Food Labeling and Expired Sanitizer Test Strips
Penalty
Summary
Food items were found improperly labeled and dated in two of three sampled refrigerators during a concurrent observation and interview in the kitchen. In Refrigerator 1, a container holding multiple individual serving-sized salad dressing containers was not labeled and had no open or use-by dates. In Refrigerator 3, a large plastic container of mustard sauce had a best-by date of 10/21/2025, the Italian salad dressing container’s used-by date was not legible, and chocolate syrup had a used-by date of 11/30/2025. The Director of Food Services stated that all food items should be labeled with names and have an opened and used-by date, and that expired, unlabeled, and undated food items should not be used in the kitchen. During a concurrent observation and interview in the kitchen dishwashing area, the Director of Food Services tested the dishwasher sanitation strength of a clean food tray after it was sanitized with a chlorine test strip. The test strip container showed an expiration date of 10/2025, and the Director of Food Services confirmed that the test strips were expired. During a later interview, the Director of Food Services stated that if expired chlorine test strips were used, the cleanliness of food tray items could not be verified and this could result in residents becoming sick.
Missing CNA Competency Assessments
Penalty
Summary
The facility failed to provide competency assessments for four of four CNA/RNA staff members. During record review, the DSD did not have competency checked off as demonstrated for the skill of weighing residents for three CNAs and for providing range of motion exercises for one RNA. In interview, the DSD stated that the CNAs and RNA might not follow the steps listed in the competency and that something unsafe could occur with residents. The DON stated that staff competency is very important because it reflects the care provided to residents and that if competencies are not completed, staff could make errors in providing care. The facility’s Competency Checks-CNA policy, dated March 2025, states that nursing assistants employed or contracted by the facility will participate in a facility-specific, competency-based staff development and training program and demonstrate specific competencies and skill sets necessary to care for residents.
Inaccurate narcotic counts and incomplete destruction documentation
Penalty
Summary
The facility failed to ensure narcotic drug records were accurate for Medication Cart 3 and Medication Cart 4. For Resident 15, the face sheet showed diagnoses including major depressive disorder, epilepsy, anxiety, and COPD. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills and substantial assistance needed with ADLs. During observation at Medication Cart 3, the morphine bottle for Resident 15 contained about 16 mL, while the narcotic medication documentation recorded 13.75 mL. The LVN and RN both stated the amount in the bottle did not match the narcotic form, and the RN stated the discrepancy could result in possible narcotic diversion. For Resident 49, the face sheet showed diagnoses including bladder cancer, Alzheimer's disease, cerebral infarction, and dementia. The MDS indicated severely impaired cognitive skills and dependence on staff for ADLs. During observation at Medication Cart 4, the morphine bottle for Resident 49 contained about 24 to 25 mL, while the narcotic medication form recorded 15 mL. The LVN and RN both stated the documentation did not match the amount in the bottle, and the RN stated the inaccurate narcotic count documentation could result in a medication error and possible narcotic diversion. The report also identified a failure related to narcotic destruction for Resident 146. The face sheet showed diagnoses including malignant immunoproliferative disease, sialadenitis, pulmonary fibrosis, and fibromyalgia. The H&P stated the resident had capacity to understand and make decisions, and the MDS indicated intact cognitive skills and partial assistance with ADLs. During review of the narcotic destruction record, the DON stated unused narcotic medication had been destroyed by incineration after discharge, but only the DON signed the destruction log and the pharmacist did not. The DON stated both were responsible for signing the destruction log, and the facility policy stated controlled substances are counted upon delivery and waste or disposal is done in the presence of the nurse and a witness who also signs the disposition sheet.
Undated Multi-Dose Medications and Improper Storage of Refrigerated Medication
Penalty
Summary
Drugs and biologicals were not consistently labeled in accordance with accepted professional principles. During observation of the first floor medication storage room, an opened tuberculin vial was found without an open date. In medication cart 2, an opened box of Omeprazole tablets was not labeled with an open date. In medication cart 3, two opened boxes of Tamiflu were also undated, and in medication cart 4, one opened box of anti-diarrheal medication was not labeled with an open date. The facility policy titled, Administering Medications, revised 8/2025, stated that the date a multidose container is opened must be recorded on the container. The facility also failed to refrigerate an opened Acidophilus bottle in medication cart 1. During interview, an LVN stated the opened Acidophilus label indicated it should be refrigerated after opening, but it was not returned to the refrigerator after medication administration. The facility policy titled, Storage of Medications, revised 7/2025, stated that medications requiring refrigeration are stored in a refrigerator located in the medication room or other secured location.
Infection Control Lapses: Missed Hand Hygiene and Uncapped G-Tube
Penalty
Summary
Failure to provide and implement an infection prevention and control program was identified when staff did not perform hand hygiene before assisting two residents. During observation, a CNA entered a resident’s room, touched the resident to place an updated identification band, and exited without performing hand hygiene. The CNA later stated that if hand hygiene is not performed, residents can get infected from germs transferred to them and be hospitalized from the infection. An RNS and the DON also stated that hand hygiene is expected before engaging with any resident to prevent spread of infection and adverse outcomes. The facility policy titled Hand Hygiene stated hand hygiene is indicated immediately before touching a resident and after touching a resident with soap and water or an alcohol-based hand rub. The deficiency also involved a resident with a g-tube that was observed hanging on a feeding tube pole with the end of the tube uncapped and exposed to open air. The resident had diagnoses including stage 4 pressure ulcer, dysphagia, type 2 DM, and bipolar disorder, and the MDS indicated severely impaired cognitive skills and dependence on staff for ADLs. The H&P stated the resident did not have the capacity to understand and make decisions. During the observation, the feeding tube was noted without a cap, and the LVN stated that when not in use, all gastronomy tubing must be capped to prevent bacterial growth. Another resident involved had diagnoses including interstitial pulmonary disease, cirrhosis, and moderate protein-calorie malnutrition, with limited vision and substantial to maximal assistance needed for personal hygiene, toileting, and lower body dressing. The resident’s H&P stated the resident did not have the capacity to understand and make decisions. The record also indicated high touch areas were to be cleaned hourly or as often as required with approved disinfectant per manufacturer’s instruction in the resident care environment. The report identified failures in hand hygiene and in keeping the g-tube capped when not in use, both within the facility’s infection control practices.
Resident Room Temperatures Below Required Range
Penalty
Summary
The facility failed to ensure that resident room temperatures were maintained within the required range for two sampled residents, Resident 63 and Resident 120. Resident 63 was admitted with diagnoses including arthropathy, iron deficiency anemia, hypotension, and dementia, and his H&P indicated he did not have the capacity to understand and make decisions. His MDS showed moderate cognitive impairment, though he could comprehend most conversations and communicate words or thoughts if given time. During observation, his room thermostat displayed 67 F, and he stated the room was always cold, that he had informed staff, and that the issue remained unresolved. He later stated his face was always cold, he felt uncomfortable because the room was cold, and even with blankets he still felt cold. Resident 120 was admitted with diagnoses including lumbosacral spinal stenosis, diabetes mellitus, and hypertension. Her H&P indicated she had capacity to understand and make decisions, and her MDS showed she was cognitively intact and could understand others and express wants or needs. During observation, her room thermostat displayed 69 F, and she stated it got cold in the room despite staff checking the temperature the previous day. Later, the Maintenance Manager measured Resident 63's room at 66.2 F and Resident 120's room at 64.9 F. The Maintenance Manager and Maintenance Supervisor stated the room temperatures were too cold and that resident room temperatures should be maintained between 71 F and 80 F, consistent with the facility policy titled Room Temperature.
MDS Medication Coding Was Inaccurate for Gabapentin
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents by not coding Gabapentin as an anticonvulsant medication in Section N0415 (High-Risk Drug Classes). Resident 5 was admitted with diagnoses including GT placement, cerebral infarction, and DM, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for oral hygiene, toileting hygiene, and upper and lower body dressing. The order summary showed Gabapentin 100 mg via GT in the evening for muscle spasm, but during interview the MDS nurse stated the medication should have been checked as an anticonvulsant and that the assessment was completed inaccurately. Resident 130 was admitted with diagnoses including DM, COPD, and HTN, and the H&P stated the resident had the capacity to understand and make decisions. The MDS indicated intact cognitive skills for daily decision making and moderate assistance with showering, upper and lower body dressing, and personal hygiene. The order summary showed Gabapentin 300 mg by mouth at bedtime for neuropathic pain, but the MDS nurse stated it was not encoded as an anticonvulsant medication in Section N0415. The MDS nurse stated accuracy of the MDS was important for care planning, facility reimbursement, and quality measures, and the facility policy required the person completing the MDS to sign and certify the accuracy of that portion of the assessment.
Failure to Develop Care Plan for Antifungal Medication
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for antifungal medication for one sampled resident, Resident 143. Resident 143 was admitted and later readmitted to the facility and had diagnoses including UTI, cerebral infarction, and DM. The H&P dated 1/28/2025 indicated the resident did not have the capacity to understand and make decisions. The MDS dated 9/8/2025 indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. The MAR from November to December 2025 showed Resident 143 received fluconazole 100 mg once daily for a yeast infection on 11/27/2025 through 12/3/2025. During a concurrent interview and record review on 12/4/2025, the MDS nurse stated there was no comprehensive person-centered care plan for the resident's use of antifungal medication and stated that each member of the IDT was responsible for creating one. The MDS nurse also stated it was important to have a care plan for medication to monitor side effects or black box warnings, and the ADON stated it was important to develop a care plan so staff would be aware of each resident's individualized needs. The facility policy titled Comprehensive Person-Centered Care Plan stated that a comprehensive person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Care plan not revised when resident’s condition changed
Penalty
Summary
The facility failed to review and revise the care plan for one sampled resident when her condition changed. Resident 76 was admitted with diagnoses including Alzheimer’s disease, anxiety disorder, adult failure to thrive, and osteoporosis. Her MDS dated 10/25/2025 indicated severely impaired cognitive skills for daily decision making and that she required a helper for all effort with oral hygiene, toileting hygiene, showering/bathing, dressing, rolling, sit-to-lying, chair/bed-to-chair transfer, and tub/shower transfer. Her care plan, initiated on 2/12/2024, included tab alarms in bed and wheelchair to alert staff of attempts to get up unassisted, with a target date of 11/9/2025. The resident’s fall risk evaluation dated 8/13/2025 indicated she could not get up or stand on her own and was not a high risk for falls. During observations on 12/2/2025 and 12/3/2025, she was seen sitting upright in a wheelchair sleeping or appearing sleepy, and no chair alarm was present. A CNA stated the alarms are used for residents on fall precautions and also stated Resident 76 did not need an alarm because she was contracted and unable to get up on her own. An RNS stated charge nurses and nurses are supposed to update care plans as necessary, and the facility policy stated care plans are revised when the resident’s condition changes and reviewed and updated with significant changes, unmet outcomes, readmission, and at least quarterly.
Incorrect Low Air Loss Mattress Settings for Two Residents With Pressure Ulcers
Penalty
Summary
The facility failed to ensure low air loss mattress settings were accurate for two residents with pressure ulcers. One resident had diagnoses including a stage 4 pressure ulcer, dysphagia, type 2 DM, and bipolar disorder, and was assessed as having severely impaired cognitive skills and dependence on staff for ADLs. During observation, the resident was lying in bed on a low air loss mattress set at 350 lbs, and the LVN stated the resident weighed 129 lbs and that the mattress was on the wrong setting. A second resident had diagnoses including necrosis of the amputation stump, DM, peripheral vascular disease, and a stage 3 pressure ulcer of the sacral region. The resident required help for all effort to roll, sit to lying, and lying to sitting. The care plan indicated the resident would have a low air loss mattress and that staff were to monitor proper setting, placement, and functioning every shift. The resident weighed 150 lbs, but during observation the low air loss mattress was set at 225 lbs. The TN and RNS both stated the setting was incorrect and that the mattress setting is based on the resident's weight.
Failure to Provide Ordered 1:1 Supervision
Penalty
Summary
The facility failed to ensure continuous supervision for one resident who was assessed as needing 1:1 monitoring due to poor safety awareness. The resident’s face sheet showed diagnoses including dementia, type 2 diabetes, cardiomyopathy, and benign prostatic hyperplasia. The MDS dated 11/26/2025 indicated the resident’s cognitive skills were severely impaired and that he was dependent on staff for ADLs. The H&P dated 6/16/2025 stated the resident did not have the capacity to understand and make decisions. The resident’s care plan, titled "Resident is on 1:1 sitter," dated 8/24/2025, directed continuous monitoring. However, during observation on 12/2/2025 at 10:49 a.m., the resident was seen lying in bed with floor mats on both sides and an empty seat at the end of the bed. During a concurrent interview, CNA 9 stated that continuous monitoring required a staff member to be with the resident at all times, and that no staff member was present to monitor the resident at that time. CNA 9 also stated the resident required continuous monitoring and that not having the 1:1 sitter at the bedside as ordered could result in falls and/or accidents and was a safety hazard.
Failure to Provide Bladder Training for a Resident with Urinary Incontinence
Penalty
Summary
The facility failed to ensure that one sampled resident was provided bladder training. Resident 13 was admitted with diagnoses including osteoarthritis of both hips, hyperlipidemia, and hypertension, and the admission history and physical indicated the resident had the capacity to understand and make decisions. The MDS dated 9/16/2025 indicated the resident’s cognitive skills for daily decision making were intact, that the resident required supervision with oral hygiene, toileting hygiene, and personal hygiene, and that the resident was frequently incontinent of urine. The MDS also indicated that a trial of a toileting program such as scheduled toileting, prompted voiding, or bladder training had not been attempted. During the concurrent interview and record review, the MDS nurse stated there was no documented evidence that staff implemented bladder training and that the resident would benefit from a trial of a toileting program to reduce incontinence. The ADON stated that offering a toileting program such as bladder training was important for the resident’s dignity. The facility policy on Toileting Program stated that options for managing urinary incontinence include behavioral programs, toileting plans, and medication therapy.
Kinked Oxygen Tubing Not Identified for Resident on Continuous Oxygen
Penalty
Summary
The facility failed to ensure the oxygen tubing was not kinked for one sampled resident, Resident 109. Resident 109 was admitted with diagnoses including chronic respiratory failure with hypoxia, emphysema, and cerebral ischemia. The resident’s MDS dated 4/29/2025 indicated the resident was receiving oxygen therapy, and the physician order dated 4/23/2025 specified continuous oxygen at 2 liters per minute. The care plan titled, At Risk for Impaired Airway Clearance related to Chronic Respiratory Failure with Hypoxia, dated 4/23/2025, identified the goal of maintaining a clear airway. During an observation on 12/2/2025 at 12:01 P.M. in the dining room, Resident 109’s oxygen tubing was observed kinked at the humidifier port. During interviews, CNA 3 stated she would notify licensed nurses if there was a kink in a resident’s oxygen tubing and that a kink could result in a lower oxygen saturation. The ADON stated that if there was a kink or obstruction in the oxygen tubing, the resident would be assessed and the tubing replaced, and that the CNA would notify the licensed nurses so the nurse could assess the resident. The facility’s policy titled Respiratory Services/Oxygen Administration, dated February 2024, indicated to check the oxygen tubing to make sure it is free of kinks.
Failure to Assess Resident Pain
Penalty
Summary
The facility failed to assess pain for one sampled resident, Resident 112, in accordance with its pain management policy and procedure. Resident 112’s history and physical documented diagnoses including dementia and chronic kidney disease, and the physician had ordered acetaminophen 325 mg, 2 tablets by mouth every 6 hours as needed for mild pain. The resident’s Pain Level Summary showed the last pain assessment was completed at 2:24 A.M., but during an observation and interview at 10:38 A.M., the resident was seen in the room with a frowning face and stated he had pain in his right forearm. During an interview, a CNA stated the resident had reported pain and that licensed nurses should assess the resident and provide medication after assessment. An RN later stated that licensed nurses should perform a pain assessment every shift and daily, and that she had not performed any pain assessment for Resident 112 and there was no documentation of an assessed pain in the chart. When the RN later observed and interviewed the resident, she stated the resident had mild pain and would receive acetaminophen per physician order. The facility’s March 2025 pain assessment policy stated that pain recognition includes observing the resident for behavioral signs such as grimacing or frowning and asking whether the resident is experiencing pain.
Inaccurate Weekly Nursing Assessment Documentation
Penalty
Summary
The facility failed to ensure the weekly nursing assessment for one resident was accurate. Resident 56 was admitted with diagnoses including chronic respiratory failure, obesity, dementia, and diabetes. The resident’s MDS dated 7/7/2025 indicated bowel incontinence, and the daily bowel movement log from 11/5/2025 to 12/4/2025 showed a bowel movement every day. However, the weekly nursing assessments dated 11/6/2025, 11/12/2025, and 11/26/2025 contained discrepancies about the resident’s last bowel movement, including entries stating the last BM was 10/22/2025 and 11/19/2025. During interview, the ADON stated the weekly nursing assessments had discrepancies regarding how often the resident had bowel movements and should be updated to reflect correct information. The facility policy titled Charting and Documentation stated documentation in the medical record will be complete and accurate.
Missing Hospice Visit Calendar
Penalty
Summary
The facility failed to ensure hospice services met professional standards for one sampled resident who was on hospice care. Resident 15 was initially admitted to the facility and later readmitted, with diagnoses including COPD, cerebral infarction, and dysphagia. The resident's H&P dated 12/5/2025 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 11/7/2025 indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident required substantial assistance with eating, oral hygiene, toileting hygiene, and upper and lower body dressing. During a concurrent interview and record review on 12/3/2025, LVN 1 stated there was no hospice calendar with the scheduled visits for the hospice team available for the month of December 2025. LVN 1 stated the hospice calendar was a coordinated schedule for hospice services. The ADON stated the hospice calendar served as a collaboration among the facility's IDT and hospice team for continuity of care. The facility policy titled Hospice, dated 3/2025, stated the facility was to communicate with the hospice provider to ensure the resident's needs were addressed and met 24 hours per day and to collaborate with hospice representatives and coordinate facility staff participation in the hospice care planning process for residents receiving these services.
Call Light Not Within Reach for Resident With Left-Sided Weakness
Penalty
Summary
The facility failed to ensure that Resident 81’s call light was within reach. Resident 81’s admission record indicated hemiplegia, hemiparesis, and aphasia. The H&P stated that Resident 81 had left-sided weakness and lacked the capacity to understand and make decisions. The MDS indicated short- and long-term memory problems, severely impaired cognitive skills for daily decision making, and dependence on staff for toileting, personal hygiene, and getting dressed. During an observation and interview, Resident 81 was fully dressed, sitting in a wheelchair, watching TV, with a bedside table in front of them, and stated they could not reach the call bell device that was under a pillow on the bed. CNA 4 stated Resident 81 would not be able to reach the call bell if it was placed under the pillow because Resident 81 only used their left hand. RNS 1 stated Resident 81 could not reach the call bell and would not be able to verbally request help. The DON stated the call bell is a means of communication between staff and residents and is very important in an emergency. The facility policy stated the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Unattended Cigarettes Left in Designated Smoking Area
Penalty
Summary
The facility failed to ensure that a pack of cigarettes was not left unattended on a bench in the designated smoking area behind the chapel. During an observation on 12/03/2025 at 12:38 PM, surveyors found a pack of cigarettes inside a crocheted pouch on a wooden bench in the patio smoking area. During a concurrent interview, the DON stated that staff store cigarettes in a locked area and provide residents with designated smoking times, and that residents are not permitted to have cigarettes or lighters in their possession for safety reasons. During a later observation and interview in the same smoking area, the pack of cigarettes was still left unattended on the bench. The DON stated this created a risk because the cigarettes were easily accessible and residents could take and smoke them, and that there was a risk of burns. The AA stated the designated area is checked daily and was unsure how the cigarettes were left unattended, adding that cigarettes are supposed to be locked in the activities room drawer. The facility policy titled Environmental Safety, revised 3/2025, stated the facility must maintain a safe and hazard-free environment and prevent accidents, injuries, and hazards through proper handling, storage, and disposal of hazardous materials.
Incomplete Facility Assessment Missing Contingency Plan
Penalty
Summary
The facility failed to ensure that a contingency plan was developed and included in the Facility Assessment. During a concurrent interview and record review on 12/3/2025 at 3:25 p.m. with the Administrator, the Facility Assessment dated [DATE] was reviewed, and the Administrator stated he was responsible for updating it. He stated the Facility Assessment was incomplete and did not include the contingency plan, including staffing needs during an emergency that would affect resident care. The Administrator further stated the Facility Assessment did not indicate the facility's plan of action for staffing shortage during an emergency. He stated the contingency plan should be included in the Facility Assessment so the facility would be able to provide proper care and operate without delay for resident safety. The facility's Policy and Procedure titled Facility Assessment, dated 3/2025, stated the assessment is conducted annually to determine and update the capacity to meet resident needs and competently care for residents during day-to-day operations, including nights and weekends, and emergencies. CMS reference QSO-24-13-NH, dated 6/18/2024, was also reviewed and stated the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
QAA Committee Lacked Required Infection Preventionist Participation
Penalty
Summary
The facility failed to ensure the Infection Preventionist Nurse attended, participated in, and provided findings on a regular basis to the Quality Assessment and Assurance committee. During a concurrent interview and record review with the Administrator, the facility’s QAA committee and QAPI Action Plan were reviewed, and the Administrator stated the IPN did not attend, participate, or take part in the QAA and QAPI meetings on 7/28/2025 and 10/23/2025. The Administrator also stated it was a requirement for the IPN to attend QAPI meetings quarterly so infection control issues identified in the facility could be discussed and updated state and federal infection control regulations could be shared. Review of the facility’s Quality Assurance Performance Improvement Plan, dated 3/2025, showed the committee members were to include the Administrator or designee, DON, Medical Director, Infection Preventionist, and a representative of other departments, and that the committee was to meet at least quarterly or more often as necessary.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) in a timely manner for one resident. The resident, who had severe cognitive impairment and required moderate assistance with activities of daily living, was observed by staff with a bump and discoloration on the back of her head. The initial observation of the injury was made by a Certified Nurse Assistant (CNA) during the evening shift, who reported it to the Registered Nurse Supervisor. The CNA later inquired if the injury had been reported to the Director of Nursing (DON), the Administrator, and CDPH, and was told by the RN Supervisor that it had been taken care of. However, subsequent staff interviews and record reviews revealed that the injury was not reported to the appropriate authorities until the following day, after being observed again by another CNA and reported up the chain of command. The facility's policy required that injuries of unknown origin or suspected abuse be reported within two hours to the appropriate agencies. Interviews with the DON and Administrator confirmed that the injury should have been reported the previous day, in accordance with policy and regulatory requirements. The delay in reporting resulted in a delay of an onsite investigation by CDPH and had the potential to place all residents at risk for abuse.
Failure to Develop Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was receiving heparin injections for deep vein thrombosis prophylaxis. The resident had multiple diagnoses, including atrial fibrillation, subdural hemorrhage, repeated falls, and dementia, and required substantial to maximal assistance with activities of daily living. Despite a physician's order to administer heparin subcutaneously every 12 hours, there was no care plan in place to address the administration of this medication or to monitor for potential side effects and complications, such as bleeding. The deficiency was identified through a review of the resident's admission record, Minimum Data Set, physician's orders, and medication administration record, as well as an interview with the Director of Nursing. The DON confirmed that a care plan should have been initiated when the heparin order was received, in accordance with the facility's policy and procedure for developing comprehensive, person-centered care plans. The absence of a care plan meant that necessary interventions and monitoring for the resident's safety were not documented or implemented.
Expired Food Items Found in Storage
Penalty
Summary
The facility failed to ensure that food items were discarded after their use-by dates, as observed during a survey. In the dry storage room, several expired food items were found, including baking soda powder, colander seeds, red food coloring, and breadcrumbs. The Dietary Procurement Personnel (DP 1) acknowledged that these items should have been labeled with an opened date and a use-by date, and discarded once expired. DP 1 emphasized the importance of tracking these dates for safety reasons, as serving expired food could pose a risk of illness to residents. The Dietary Manager confirmed the facility's process of labeling food items with opened and use-by dates and stated that expired items should be discarded to prevent them from being served to residents. The facility's policy and procedure on food storage, although undated, indicated that the Nutrition Services Manager is responsible for ensuring proper storage and labeling of food items. The presence of expired food items in storage suggests a lapse in adherence to these procedures, potentially compromising resident safety.
Infection Control Deficiencies in Laundry, Rehabilitation, and Equipment Use
Penalty
Summary
The facility failed to implement appropriate infection control practices in several areas. Firstly, the laundry was not washed at the correct temperature as per the facility's policy and procedure. The laundry staff, including the Laundry Aide and Maintenance Supervisor, were following a signage on the washing machine that indicated a temperature range of 140-145 degrees Fahrenheit. However, the facility's policy required soiled linen to be washed at a temperature range of 158-176 degrees Fahrenheit. This discrepancy was not known to the staff, indicating a lack of awareness and adherence to the facility's infection control policies. In the rehabilitation office, reusable cold modality packs used for residents were stored in the same combination freezer/refrigerator as staff food containers. The Assistant Director of Rehabilitation confirmed this practice, which was against infection control protocols. The Infection Preventionist and Director of Nursing both stated that resident equipment should not be stored with staff food due to the risk of contamination. The facility's policy emphasized the need for a safe and sanitary environment to prevent disease transmission, which was not followed in this instance. Additionally, a Restorative Nursing Aide used a cloth gait belt with a resident and attempted to disinfect it with wipes, which was inadequate for porous materials. The Infection Preventionist and Director of Nursing confirmed that cloth gait belts must be washed to be properly disinfected, and that disinfecting wipes are only effective on non-porous materials like plastic gait belts. The facility's policy required reusable items to be cleaned and disinfected between residents, which was not adhered to in this case.
Failure to Post Complaint Investigation Results
Penalty
Summary
The facility failed to post the results of complaint investigations conducted by the California Department of Public Health (CDPH) over the past three years in areas that are prominent and accessible to residents, family members, and visitors. During an observation and interview, the Director of Nursing (DON) acknowledged that the survey binder available at nursing station 2 was incomplete and did not include these results. Instead, the complaint investigation results were kept in a separate binder in the DON's office, which was not accessible to residents and their families. The DON admitted that this practice violated residents' rights by not making the information readily available. The Administrator (ADM) confirmed that it was his responsibility to ensure the survey binder and complaint investigation results were posted as required. The facility's policy and procedure on Resident's Rights, as well as the admission packet, clearly stated that residents have the right to examine the results of the most recent surveys and any plans of correction. However, the facility did not comply with these requirements, thereby placing residents, family members, and visitors at risk of not being informed about the facility's compliance status and past performance.
Failure to Conduct Annual Competency Assessments for Nursing Staff
Penalty
Summary
The facility failed to ensure that annual competency assessments were conducted for four out of five randomly selected staff members, which is a requirement to ensure that nursing staff have the necessary skills to provide safe and effective care to residents. During a review of employee records, it was found that a Licensed Vocational Nurse (LVN) and three Certified Nurse Assistants (CNAs) did not have the required annual competency assessments on file. This oversight was confirmed during an interview with LVN 7, who indicated that the Director of Nursing (DON) was responsible for completing these assessments. The DON acknowledged that competency assessments must be conducted upon hire and annually, and that staff cannot work on the floor without completing and passing these assessments. However, the DON stated that she had been recently hired and had not yet completed the assessments for the identified staff members. The facility's policy, dated March 2024, mandates that competency evaluations be conducted upon hire, annually, and as necessary based on the facility assessment, highlighting the importance of these evaluations in maintaining compliance with state licensing requirements.
Failure to Label Opened Medications in Medication Carts
Penalty
Summary
The facility failed to label medications with the opened date on the label for drugs stored in two of four sampled medication carts. This oversight was identified during observations and interviews with Licensed Vocational Nurses (LVNs) and a review of residents' records. The medications involved were intended for residents with various medical conditions, including epilepsy, diabetes mellitus, and end-stage renal disease, among others. The absence of an opened date on these medications raised concerns about the potential administration of expired drugs, which could lead to ineffective treatment and possible harm to the residents. During the survey, it was observed that Medication Cart 1 contained an open vial of testosterone cypionate for a resident with epilepsy and an open box of ipratropium-albuterol inhalation solution for a resident with diabetes mellitus, neither of which were labeled with an opened date. LVN 7 acknowledged that without the opened date, there is a risk of administering expired medication. Similarly, Medication Cart 2 had an opened bottle of Phenergan/codeine oral syrup, an opened tube of Nitro-Bid transdermal ointment, and an opened tube of estradiol vaginal cream, all lacking an opened date. LVN 6 confirmed the risk of administering expired medications under these circumstances. The Director of Nursing (DON) emphasized the importance of labeling medications with the opened date to prevent residents from receiving expired medications, which could lead to adverse effects. The facility's policy and procedure on medication labeling, which aligns with state and federal guidelines, was reviewed and indicated that all medications should be properly labeled. However, the failure to adhere to this policy resulted in the identified deficiency.
Failure to Dress Resident Daily
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 47, was properly dressed daily, which is a violation of the resident's right to be treated with respect and dignity. Resident 47, who has severe cognitive impairment and is dependent on staff for personal hygiene, showering, and dressing, was observed wearing a hospital gown over several days. The resident's care plan indicated that staff should assist the resident in selecting clothes and ensure that clothing is clean, age-appropriate, and in good repair. However, observations over three consecutive days showed that the resident remained in a hospital gown, indicating a failure to adhere to the care plan. Interviews with staff, including an LVN, two CNAs, and the DON, revealed that the resident was not dressed unless taken out of bed, which was not consistent with the facility's policy on dignity. The staff acknowledged the importance of dressing the resident daily to promote a sense of dignity and respect. The facility's policy emphasized that residents should be cared for in a manner that enhances their well-being and self-esteem, including being dressed in their preferred clothing. Despite this policy, the resident was not dressed in regular clothing, which could impact their sense of self-worth and dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one resident, identified as Resident 14, which could potentially delay necessary care and services. Resident 14 was admitted with several medical conditions, including a displaced fracture of the left femur, cerebral infarction with hemiplegia and hemiparesis, and unspecified dementia. The resident was dependent on staff for various activities of daily living, such as toileting, eating, dressing, showering, and personal hygiene. During an observation, it was noted that the call light was placed on a dresser behind the bed, out of the resident's reach, which was confirmed by a Certified Nursing Assistant (CNA) who then moved the call light within reach. The Director of Nursing (DON) acknowledged that call lights should be within residents' reach to enable them to call for help when needed. The facility's policy, dated April 2024, also indicated that the purpose of the call light policy was to ensure residents have the necessary means of communication with nursing staff by keeping the call light within reach. This oversight in adhering to the policy resulted in a deficiency as it compromised the resident's ability to communicate their need for assistance.
Failure to Notify Physician of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to notify the physician of a significant weight loss in Resident 24, who experienced an 18-pound weight loss, equating to 11.8% over three months. Resident 24 was admitted with diagnoses including failure to thrive, urinary tract infection, and cerebral infarction with left hemiplegia and dysphagia. Despite the significant weight loss documented in the resident's Weights and Vitals Summary, there was no documentation indicating that the physician was notified, as confirmed by the Director of Nursing (DON). The facility's policy required physician notification for weight changes, but this was not adhered to, leading to a potential risk for further weight loss. Additionally, the facility failed to notify the physician about the swollen ankles of Resident 39, who was admitted with conditions such as gastrostomy, Parkinson's disease, and atherosclerotic heart disease. During an observation, Resident 39 was noted to have swollen and red ankles while sitting in a wheelchair. Licensed Vocational Nurse (LVN) 5 acknowledged the swelling as a new finding and stated that the physician should have been notified. However, the DON confirmed that there were no records of the physician being informed about this change in condition. The facility's policy on notifying physicians of changes in a resident's condition was not followed in both cases. The policy required notification of the physician and responsible parties when there was a significant change in a resident's condition, such as weight loss or swelling. The failure to notify the physician in these instances placed the residents at risk for further complications, as the necessary medical interventions were not implemented in a timely manner.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, leading to incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS). For one resident, the MDS assessment did not reflect a diagnosis of schizophrenia under Section A, which is crucial for determining mental illness conditions. This oversight was acknowledged by the MDS Nurse during a review, who confirmed that the diagnosis was not checked in the MDS assessment, despite the resident having a history of schizophrenia and dementia. The nurse emphasized the importance of accuracy in the MDS for both resident care and facility reimbursement. For another resident, the facility failed to update the MDS quarterly as required. The MDS Nurse admitted that the resident's MDS was not updated on time due to other responsibilities such as meetings and document updates. The Director of Nursing (DON) also confirmed that the MDS should be updated quarterly to ensure the staff can continue the resident's plan of care and monitor for any improvements or declines. The facility's policy and procedure on the accuracy of assessments highlighted the need for comprehensive assessments to be conducted quarterly, which was not adhered to in this case.
Failure to Accurately Complete PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident diagnosed with schizophrenia. The resident, who was initially admitted and later readmitted to the facility, had a history of schizophrenia and dementia, which impaired their cognitive abilities and decision-making capacity. Despite these diagnoses, the PASRR Level 1 screening incorrectly indicated that the resident had no serious mental illness and was not receiving psychotropic medications, leading to the case being closed without a Level 2 evaluation. During a review of the resident's records, it was found that the PASRR Level 1 screening was not completed accurately, as confirmed by the MDS nurse. The facility's policy required a new PASRR to be completed when a new mental health disorder was diagnosed, but this was not done. The failure to refer the resident for a Level 2 evaluation potentially resulted in the resident not receiving appropriate treatment recommendations for their schizophrenia.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized person-centered care plans with measurable objectives, timeframes, and interventions for three residents. For Resident 19, the facility did not address the need for a one-to-one sitter despite the resident's history of falls and cognitive impairment. During an interview, a Licensed Vocational Nurse (LVN) confirmed that there was no care plan or physician order for the use of a sitter, which is necessary for staff to ensure the resident's care goals are met. Resident 24 experienced significant weight loss over a three-month period, dropping from 153 pounds to 135 pounds. Despite this, the facility did not create a care plan to address the weight loss, which is crucial for implementing nutritional interventions. The Director of Nursing (DON) acknowledged the lack of a care plan and emphasized the importance of care planning as a guide for staff to meet the resident's specific needs. For Resident 39, who had swollen ankles and redness, the facility did not develop a care plan with interventions to address this condition. Observations confirmed the swelling, and an LVN stated that a care plan should have been developed to prevent the condition from worsening. The DON noted that interventions should be put in place once a condition is identified, and follow-ups are necessary to ensure the resident's condition improves. The facility's policy requires comprehensive, person-centered care plans to meet residents' needs, but this was not adhered to in these cases.
Failure to Provide Garden Strolls for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 47, was taken outside for a garden stroll, which was an activity important to the resident's mental and emotional well-being. Resident 47, who was admitted to the facility with diagnoses including epilepsy, chronic kidney disease, and benign prostatic hyperplasia, was noted to have severely impaired cognition and was dependent on staff for personal care. The Minimum Data Set (MDS) indicated that it was very important for Resident 47 to go outside for fresh air when the weather was good, and the Activities Review Record showed a preference for sensory stimulation and garden strolls. Despite these documented preferences, the Activity Attendance Record for September 2024 showed no documentation of Resident 47 being taken outside for a garden stroll. Interviews with facility staff, including an Activity Assistant and a Licensed Vocational Nurse, confirmed that there was no set schedule for taking Resident 47 outside, and they had not observed the resident being taken for garden strolls. The Director of Nursing acknowledged that staff should offer and take Resident 47 outside daily when the weather was favorable, using nonverbal cues to assess the resident's interest. The facility's policy emphasized the importance of individualized care and engagement in meaningful activities, which was not adhered to in this case.
Failure to Monitor Pacemaker in Resident
Penalty
Summary
The facility failed to ensure that a resident with a pacemaker received treatment and care in accordance with professional standards of practice. The resident, who was admitted with diagnoses including acute on chronic congestive heart failure and hypertensive heart disease, had a Boston Scientific pacemaker implanted in 2017. Despite the care plan indicating the need for regular pacemaker evaluations, the resident reported that their pacemaker had not been checked since admission to the facility. The Director of Nursing confirmed that a scheduled pacemaker evaluation was canceled and not rescheduled, resulting in the pacemaker not being checked for four years. The facility's policy required pacemaker checks every three months or yearly, depending on the model, to prevent potential malfunctions. The failure to adhere to this policy posed a risk of pacemaker failure, which could lead to serious medical complications.
Failure to Conduct Timely Joint Mobility Assessments
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for three residents who had limited ROM or were assessed at risk for decline in joint ROM. The facility did not ensure that Residents 64, 14, and 15 received timely quarterly rehabilitation joint mobility screens to monitor changes in joint ROM, as indicated in their care plans. This deficiency was identified through observation, interview, and record review. Resident 64, who was admitted with diagnoses including dementia and cerebral infarction, was observed with functional limitations in both upper and lower extremities. The resident's care plan required quarterly assessments of joint mobility, but the Joint Mobility Assessments (JMA) were not completed on time. The last assessment was conducted on 5/21/2024, and the subsequent assessment was overdue by the end of August 2024. The Assistant Director of Rehabilitation (ADOR) confirmed the delay and emphasized the importance of timely assessments to monitor and address any decline in ROM. Similarly, Resident 14, with a history of severe cognitive impairment and hemiplegia following a cerebral infarction, did not receive a timely JMA after the last one on 6/17/2024. The assessment was due by the end of September 2024. Resident 15, diagnosed with dementia and osteoarthritis, also experienced a delay in their JMA, which was completed late on 8/28/2024. The Director of Nursing (DON) acknowledged the responsibility of rehabilitation staff to complete JMAs timely to prevent deterioration in residents' physical capabilities, which could affect their balance, ability to feed themselves, and mobility.
Failure to Implement Fall Prevention and Sharps Disposal Protocols
Penalty
Summary
The facility failed to ensure that Resident 81 had floor mats at the bedside to prevent injury from a fall. Resident 81, who was diagnosed with dementia, COPD, and anxiety, was identified as having severely impaired cognition and was dependent on staff for personal care. The resident was assessed as high risk for falls, and the care plan included the use of floor mats as a preventive measure. However, during observations on two separate occasions, no floor mats were present at the bedside. Interviews with LVN 5 and the DON confirmed the absence of floor mats and acknowledged the increased risk of injury to Resident 81 without them. Additionally, the facility did not replace sharps containers in rooms 221, 321, and 333 when they were at least 75% full, as required by the facility's policy. Observations revealed that the containers were overfilled, with one container having a razor protruding from it. LVN 8 and RN 1 confirmed the importance of replacing sharps containers to prevent needlestick injuries and stated that it was the responsibility of all nurses to ensure containers were changed when full. The facility's policy indicated that containers should be sealed and replaced when they are 75% to 80% full.
Failure to Maintain Oxygen Therapy Equipment
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the maintenance of oxygen therapy equipment for a resident, identified as Resident 23. The deficiency was observed when the oxygen tubing and humidifier in Resident 23's room were found to be undated and unlabeled, contrary to the facility's policy that requires these items to be dated and changed every seven days. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the responsibility of licensed nurses to label and date the equipment upon opening. The LVN also noted that failing to change the oxygen tubing within the specified timeframe could lead to bacterial growth and potential respiratory infections. Resident 23, who was initially admitted to the facility with acute respiratory failure with hypoxia and obstructive sleep apnea, had an active order for Bilevel Positive Airway Pressure (BIPAP) therapy at 2 liters per nasal cannula every night. The Director of Nursing (DON) emphasized the importance of dating the humidifier and changing the oxygen tubing weekly for infection control and ensuring the patency of the tubing to deliver the correct oxygen concentration. The facility's policy, dated February 2024, clearly states the requirement to change the oxygen cannula and tubing every seven days and to mark the humidifier bottle with the date and initials upon opening.
Physician Order Missing for 1:1 Sitter
Penalty
Summary
The facility failed to ensure that a physician signed an order for a one-to-one (1:1) sitter for a resident, identified as Resident 19, who was under close supervision due to a history of falls. During an observation and interview, a staff member was noted to be sitting within arm's reach of Resident 19, serving as the 1:1 sitter. The staff member confirmed her role was to prevent falls due to the resident's history. However, upon reviewing Resident 19's medical chart, it was discovered that there was no physician's order for the sitter, which is a requirement according to the facility's policy. Resident 19 was readmitted to the facility with diagnoses including muscle weakness, lack of coordination, and dementia, which affected cognitive abilities. The Minimum Data Set (MDS) assessment indicated that Resident 19 was not cognitively intact. Despite these conditions, the necessary physician's order for the sitter was missing, as confirmed by a Licensed Vocational Nurse (LVN) during a record review. The facility's policy, dated March 2024, clearly states that the use of sitters must be approved by the resident's attending physician, highlighting the oversight in this case.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide physical therapy (PT) services to a resident, despite an active physician's order for PT evaluation and treatment. The order was dated 4/5/2024, but no PT services were provided to the resident, who was part of a sample of 12 residents. This oversight was identified during an observation and interview on 10/2/2024, where the resident was seen sitting in a wheelchair and able to drink with assistance. The resident had been admitted with diagnoses including dementia and cerebral infarction, and the Minimum Data Set (MDS) indicated severe cognitive impairment and functional limitations in both upper and lower extremities. The Assistant Director of Rehabilitation (ADOR) confirmed that there was no PT evaluation or documentation explaining the lack of PT services for the order dated 4/5/2024. The ADOR stated that the rehabilitation department should have seen the resident within 24 hours to complete an evaluation. The Director of Nursing (DON) also confirmed that the order should have been carried out and that the nurse receiving the order should have communicated it to the rehabilitation department. The facility's policy indicated that rehabilitative services should be provided upon the written order of the resident's attending physician.
Failure to Maintain Timely Medical Records
Penalty
Summary
The facility failed to maintain timely medical records for a resident, identified as Resident 63, when their Joint Mobility Assessment (JMA) dated November 20, 2023, was not documented until October 3, 2024. This delay in documentation was discovered during a record review, where it was noted that the JMA was blank and marked as not completed. The Assistant Director of Rehabilitation (ADOR) confirmed that the JMA was signed almost a year after the effective date, which did not meet professional standards for timely documentation. The ADOR was unsure of the reason for the delay, as the therapist responsible was not present at the facility on the day of the review. Resident 63 was admitted with diagnoses including Parkinson's Disease and cerebral infarction, and was assessed as cognitively intact with functional limitations in the range of motion on one side of the upper extremity. The Director of Nursing (DON) emphasized the importance of timely and accurate documentation to ensure continuity of care and proper follow-up. The facility's policy on charting and documentation, dated March 2024, required that all services provided to residents be documented objectively, completely, and accurately. The failure to document the JMA in a timely manner had the potential to result in inaccurate medical documentation and delay appropriate interventions for Resident 63.
Failure to Ensure Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the representative of a resident understood the arbitration agreement they were signing. The resident, who was not cognitively intact, was admitted with diagnoses including hypertension and a history of falling. The representative, referred to as FM 1, signed the arbitration agreement without a full understanding of its implications. During interviews, FM 1 stated that no one from the facility explained the form, and she had to seek information online to understand what she was signing. The Admissions Coordinator (AC) confirmed that the arbitration agreement was part of the admissions packet and stated that she would answer any questions if asked. However, she admitted that she did not speak with FM 1 about the agreement. Additionally, the facility lacked a specific policy on arbitration, only having a policy on arbitration mediation, which outlines the process once arbitration is initiated. This lack of communication and policy clarity led to the representative entering into an agreement without proper understanding.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for a resident by not involving a hospice representative in the interdisciplinary team care conference meeting. The resident, who was diagnosed with Alzheimer's Disease and hypertension, was admitted to hospice care but lacked the capacity to understand and make decisions. The facility's records did not show participation of a hospice representative in the care conference, which was crucial for coordinating the resident's care and ensuring continuity. Additionally, the facility did not maintain a hospice calendar with scheduled visits for the hospice team, and the physician's certification for hospice benefit was not updated or available in the resident's medical record. This oversight resulted in the resident no longer being under hospice care, as the last certification had expired. The facility's policy required a coordinated care plan between the facility, hospice agency, and resident/family, which was not adequately implemented, potentially leading to a lack of coordination in hospice care delivery.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was updated and posted daily in a visible and prominent place. During an observation at the front desk in the main lobby, the Direct Care Service Hours Per Patient Day (DHPPD) form was found to be dated three days prior. Similarly, at the second-floor northeastern nursing station, the DHPPD was also outdated by four days. A Certified Nursing Assistant confirmed that the DHPPD had not been updated for at least three days. The Director of Staff Development acknowledged that the DHPPD at the front desk was not updated over the weekend and emphasized that it should be updated daily, including weekends and holidays. The facility's policy requires that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel responsible for resident care be posted in a prominent location in a clear and readable format.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
The facility failed to ensure that the head of the bed (HOB) was elevated to the physician-ordered angle of 30 to 45 degrees for a resident receiving gastrostomy tube (GT) feeding. During an observation and interview, it was noted that the resident's HOB was only elevated to 20 degrees while receiving Jevity 1.5 cal at 65 cc per hour. The treatment nurse acknowledged that the HOB should be elevated to 30 degrees to prevent aspiration. The resident involved had a medical history of dysphagia, respiratory failure, and toxic encephalopathy, and was dependent on staff for various activities of daily living. The resident's care plan and physician's orders both specified the need for the HOB to be elevated to 30 to 45 degrees during and after feeding to mitigate the risk of aspiration. The facility's policy on enteral feedings also required the HOB to be elevated to at least 30 degrees during and after feeding.
Failure to Notify Responsible Party of Medical Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident about a change in the resident's condition and the subsequent medical interventions. Specifically, the responsible party was not informed about the skin discoloration observed on the resident's right wrist and elbow, the physician's order for an x-ray, and the results of the x-ray, which showed no fracture. This oversight was confirmed during an interview with the resident's family member, who stated they were unaware of the x-ray and its results. The resident in question was admitted with diagnoses including hemiplegia and hemiparesis affecting the right side, aphasia, and rheumatoid arthritis. The resident's cognitive skills were severely impaired, requiring extensive assistance with daily activities. The facility's policy mandates notifying the responsible party of any changes in the resident's medical condition, which was not adhered to in this case. An interview with a Licensed Vocational Nurse revealed an acknowledgment of the failure to notify the responsible party as required.
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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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Terrace Rehabilitation & Wellness Centre, Lp | 0.1 mi | ★★★★★ | 29 | 0 |
| St Andrews | 0.5 mi | ★★★★★ | 0 | 0 |
| Western Convalescent Hospital | 0.6 mi | ★★★★★ | 15 | 0 |
| Sunnyview Care Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Sunray Healthcare Center | 1 mi | — | 32 | 2 |
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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.