Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Sunnyview Care Center during CMS and state inspections, most recent first.
A resident with a history of traumatic subdural hemorrhage and repeated falls experienced an unwitnessed fall when attempting to get out of bed to go to the bathroom without using the call light, resulting in contact with the floor and minor injury to the nose. Despite a Change of Condition note documenting this event, two MDS assessments indicated that the resident had not had any falls since admission, entry, reentry, or the prior assessment, and no significant error assessment was completed to correct the record. The MDS Coordinator acknowledged that the event met the facility’s definition of a fall and should have been coded as such, and the DON confirmed that facility policies requiring accurate, complete documentation of incidents and accidents were not followed.
A resident with a traumatic subdural hemorrhage, repeated falls, severe cognitive impairment, and documented need for extensive assistance with transfers had a physician’s order and care plan for continuous 1:1 sitter supervision due to frequent unassisted attempts to get out of bed. The facility’s own fall risk assessment and policy on Safety and Supervision of Residents identified the need for targeted interventions and adequate supervision. Despite this, the night-shift assignment sheet did not include a 1:1 sitter, progress notes showed no evidence of 1:1 monitoring, and no staff were present at shift change. The resident subsequently got out of bed without using the call light, fell, and sustained a bump and superficial cut to the nose, with the fall unwitnessed and no sitter documented as present.
A resident with ESRD on hemodialysis, hypertension, and a history of falls experienced prolonged waits after dialysis treatments because the facility did not ensure transportation was properly notified of post-dialysis pick-up times. On at least one occasion, dialysis records showed treatment ended mid-afternoon while the resident was not picked up until several hours later, requiring the dialysis center to arrange an Uber ride back. The resident reported that transportation frequently arrived too early, too late, or not at all, and that he had waited for hours feeling tired, weak, hungry, and ignored. Review of the resident’s dialysis/transportation flyer showed it only listed the outbound pick-up time from the facility and omitted a return pick-up time, and the SSD acknowledged this omission despite a policy stating social services must help arrange needed transportation and address transportation concerns.
Licensed nurses did not perform required weekly skin progress reports for a resident with moisture-associated skin damage (MASD), despite the resident's high risk for skin breakdown due to diabetes, immobility, incontinence, and other factors. Facility policy and the care plan called for weekly assessments, but these were not completed, as confirmed by both the treatment nurse and DON.
A resident with cognitive impairment and high fall risk experienced a fall from a wheelchair, but staff did not conduct an IDT review or update the care plan as required. After a subsequent fall from bed, staff returned the resident to bed without notifying the charge nurse or assessing for injuries, resulting in a fractured femur and hospital transfer.
A resident with cognitive impairment and multiple medical conditions was not assessed for pain after a fall when a CNA failed to notify the Charge Nurse, instead returning the resident to bed and monitoring for discomfort. The facility's policy requiring immediate reporting and documentation of incidents was not followed, resulting in a delay in pain assessment and intervention.
Three residents did not have accurate MDS assessments completed, including failure to document the use of an anti-psychotic medication, significant weight loss, and the use of an anti-coagulant. These omissions were confirmed by the MDS nurse and were inconsistent with the residents' medical records and physician orders.
A resident with multiple medical conditions, who was cognitively intact and required substantial assistance with ADLs, was limited to smoking only one cigarette per day at a set time by the DON, rather than being allowed to smoke at her own preference. This restriction, imposed due to the resident's wounds and weakness, was found to violate the resident's rights as outlined in the facility's policy.
A resident with dementia, bipolar disorder, and schizophrenia, who lacked decision-making capacity, was started on Depakote and risperidone without written informed consent or an IDT meeting as required by facility policy. The DON confirmed that the necessary consent forms were not signed and no IDT meeting occurred prior to medication initiation.
A resident with severe cognitive impairment and significant ADL needs was found to have curtains hanging from a bent curtain rod, resulting in a lack of privacy and a potential safety hazard. The resident expressed feeling violated due to visibility from outside, and the Maintenance Supervisor confirmed the poor condition of the curtain and rod, which did not support a homelike environment.
Two residents with limited range of motion did not receive required services: one did not receive timely quarterly joint mobility assessments to monitor changes in ROM, and another did not receive daily passive range of motion exercises as ordered by the physician. These failures were confirmed by staff and documented in facility records, in violation of facility policies and procedures.
A resident with severe cognitive impairment and multiple medical conditions continued to have a peripheral IV catheter in place two days after the completion of IV antibiotic therapy. Facility policy required immediate removal of the catheter after therapy, but this was not done, as confirmed by staff during observation and interview.
A resident with multiple medical conditions was prescribed Lyrica, a controlled medication. The facility failed to maintain accurate documentation and accounting of the drug, with discrepancies found between the destruction log, medication bubble pack, and drug record form. The DON noted that doses were given without proper documentation, and required procedures for shift handoff and medication reconciliation were not followed, resulting in uncertainty about the drug's disposition.
A resident with multiple medical conditions was prescribed Depakote for a mood disorder, and the consultant pharmacist recommended ordering valproic acid and ammonia levels to monitor medication safety. The facility did not inform the physician or act on this recommendation, and no orders for the tests were placed, contrary to facility policy requiring timely follow-up on pharmacy consultant recommendations.
A resident with severe cognitive impairment and multiple diagnoses did not receive monthly ammonia level lab tests as ordered by the physician. Review of records showed that the required tests were not completed for several months, and there was no documentation of results, despite facility policy requiring staff to arrange for such tests.
A resident with a feeding tube, identified as being at moderate risk for infection, did not receive care in accordance with enhanced barrier precautions. An LVN was observed checking the feeding tube while wearing gloves but not a gown, despite facility policy and posted signage requiring both. The LVN later acknowledged the omission and its importance in preventing infection.
A trash dumpster lid was observed open and filled with trash during a walkthrough with the Dietary Supervisor, who confirmed that dumpsters should remain closed according to facility policy. This failure to keep the dumpster lid closed was not in accordance with the facility's waste control procedures.
A resident with a history of cognitive impairment and psychiatric diagnoses, who had been refusing prescribed antipsychotic medication, physically assaulted another resident, causing serious injuries including head trauma and a suspected facial fracture. Staff were aware of the resident's medication non-compliance and escalating paranoia but did not take effective action to prevent the assault, resulting in a violation of the facility's abuse prevention policy.
A resident with schizophrenia and a history of medication non-compliance was not provided with an IDT meeting as required by their care plan. The resident refused Lithium Carbonate on multiple occasions, and the facility failed to notify the physician or document the refusals properly. The DON acknowledged the need for an IDT meeting, which was not conducted, leading to unaddressed medication refusals.
A facility failed to adhere to its infection control policy when an LVN was observed drinking cranberry juice and placing a personal cell phone on a medication cart, both actions contrary to the facility's 'Work Practices' policy. The LVN acknowledged the risk of germ spread and illness from these actions, which violated the policy prohibiting food and drink in areas of possible contamination.
A resident with schizoaffective disorder and mobility issues fell during a shower due to the absence of a specific ADL care plan for showering supervision. Despite requiring supervision, the resident was left unsupervised by a CNA, resulting in a fall. The DON acknowledged the need for a care plan, as per facility policies, to ensure proper supervision during such activities.
A facility failed to protect and account for personal belongings of two residents, leading to a deficiency. One resident's ID, Medi-Cal card, and passport were not documented or accounted for, while another resident's Bible CDs were lost. The facility did not follow its policy on inventorying and documenting personal property, nor did it investigate the complaints of missing items.
A resident with complex medical conditions received oxygen without a physician's order, leading to low oxygen saturation levels. The LVN failed to notify the physician as required by the care plan, resulting in a delay in appropriate interventions and the resident's transfer to a hospital. The facility did not adhere to its policies on changes in condition and oxygen administration.
A resident with multiple diagnoses had discrepancies in their cognitive assessment records and experienced a change in condition that was not thoroughly documented. The facility failed to maintain complete clinical records, as vital signs and a detailed account of the resident's condition change were missing from the progress notes, contrary to the facility's policy.
The facility failed to ensure call lights were within reach for three residents, potentially delaying necessary care. A resident was found unable to reach his call light, tied to a nightstand, while two others had their call lights clipped to an overhead light cord. Staff acknowledged the oversight, and the DON confirmed the importance of accessible call lights, as per facility policy.
The facility did not perform yearly competency assessments for three CNAs, as required by policy. The DSD acknowledged the oversight, which could jeopardize resident safety by not ensuring staff have the necessary skills. The DON confirmed the importance of these assessments for maintaining care standards.
The facility failed to label three tubs of ice cream with received-by and delivery dates in Freezer #5, risking the use of expired food. Additionally, a dirty apron bin was improperly placed in the dry storage area, potentially contaminating food items. These actions were against the facility's policies, as confirmed by dietary staff and the supervisor.
The facility failed to implement proper infection control measures for two residents on Enhanced Standard Precautions due to their use of gastrostomy tubes. Staff did not wear the required PPE, specifically gowns, when administering medication via g-tube, which could lead to cross-contamination and infection spread. Both residents had significant medical conditions and were dependent on staff for daily activities, necessitating strict adherence to infection control protocols.
A resident with Alzheimer's and a seizure disorder was observed using a lap buddy restraint in a wheelchair without regular evaluations or attempts to use less restrictive measures. Staff acknowledged the lack of ongoing assessments, contrary to facility policy, which required frequent reassessment and reduction of restraints.
A facility failed to resubmit a PASRR Level I screening for a resident with epilepsy, anxiety disorder, and schizophrenia after a hospital exemption, despite the resident staying over 30 days. The MDS coordinator admitted the oversight, which was against the facility's policy requiring a new PASRR submission if a resident remains longer than 30 days. This failure potentially impacted the resident's psychiatric treatment and evaluation.
A facility failed to accurately complete the PASRR Level 1 screening for a resident with schizophrenia, resulting in the omission of a necessary Level 2 evaluation. The resident's records indicated a diagnosis of schizophrenia and dementia, but the screening did not reflect this, leading to the case being closed without further evaluation. The MDS coordinator acknowledged the error, which potentially prevented the resident from receiving appropriate treatment recommendations.
A facility failed to implement a bed alarm for a resident at high risk for falls, despite it being part of the care plan. The resident, with Alzheimer's and a seizure disorder, was found trying to get out of bed without the alarm. Interviews revealed staff were unaware of the care plan requirement, contrary to facility policy.
A resident's nasal cannula for oxygen therapy was found undated and improperly stored, risking contamination. The resident also lacked a physician's order for oxygen, which is required for safe administration. The facility's policy did not specify the need for covering oxygen tubing when not in use, contributing to the oversight.
A resident with cerebral infarction and contracture of the left hand was observed without prescribed splints, and the facility failed to document the resident's refusal to wear them. The RNA admitted to not documenting the refusal, and the LVN was unaware of the situation. The DON confirmed that documentation and reporting were required per facility policy.
Inaccurate MDS Coding of Resident Fall Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment related to a resident’s health conditions, specifically falls. The resident was admitted with diagnoses including traumatic subdural hemorrhage, repeated falls, restlessness, and agitation. An H&P dated 1/10/2026 documented that the resident had the mental capacity to understand but could not make medical decisions. An MDS dated 1/14/2026 indicated severe cognitive impairment, no acute change in mental status, no hallucinations or delusions, and that the resident required maximal assistance for bed mobility, transfers, and walking ten feet in the room. This MDS also indicated the resident had not experienced any falls since admission, reentry, or the prior assessment. On 1/16/2026, a Change of Condition (COC) documented that at 8:30 a.m. the resident got out of bed without using the call light to go to the bathroom, their knees buckled, and they made contact with the floor, sustaining a small bump and superficial cut to the nose with minimal bleeding. A subsequent MDS again documented that the resident had not had any falls since admission, entry, reentry, or the prior assessment, despite the documented fall on 1/16/2026. During interviews, the MDS Coordinator acknowledged that the 1/16/2026 event met the facility’s definition of a fall (any unintentional contact with the ground), that it was unwitnessed, and that it should have been coded as a fall on the MDS and as a fall since the prior assessment, but was not. The MDS Coordinator also confirmed that no significant error assessment was completed to correct the inaccuracy. The DON stated that facility policy requires assessments and documentation to be accurate, complete, and to include events, incidents, and accidents, and that this policy was not followed when the MDS failed to reflect the resident’s fall.
Failure to Provide Ordered 1:1 Sitter Supervision Resulting in Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Safety and Supervision of Residents policy, as well as the physician’s order and care plan, to provide continuous 1:1 sitter supervision for a resident at high risk for falls. The resident was admitted with diagnoses including traumatic subdural hemorrhage, repeated falls, restlessness, and agitation. A Rehab Fall Risk Assessment dated 1/9/2026 documented that the resident required extensive assistance for bed mobility and transfers, used a wheelchair without proper safety, did not use the call bell properly, did not demonstrate safety techniques during transfers, and lacked sufficient strength and posture in sitting or standing. The H&P dated 1/10/2026 indicated the resident had the mental capacity to understand but could not make medical decisions. A physician’s order dated 1/13/2026 required 1:1 monitoring every shift because the resident constantly attempted to get out of bed unassisted. The MDS dated 1/14/2026 showed severe cognitive impairment and a need for maximal assistance for transfers and ambulation in the room. The resident’s care plan, also dated 1/14/2026, identified non-compliance with unassisted transfers and risk of falls/injuries, and directed CNAs to provide a 1:1 sitter. Despite this, the nursing assignment sheet for the 11:00 p.m.–7:00 a.m. shift on 1/15/2026 did not list a 1:1 sitter for the resident’s room, and progress notes from 1/15/2026 at 11:00 p.m. through 1/16/2026 at 7:00 a.m. contained no indication that 1:1 supervision was provided. On the 7:00 a.m.–3:00 p.m. shift on 1/16/2026, the nursing assignment indicated that a CNA was assigned as a 1:1 sitter for the resident’s room. However, a Change of Condition note dated 1/16/2026 documented that at 8:30 a.m. the resident got out of bed to go to the bathroom without using the call light, his knees buckled, and he made contact with the floor, sustaining a small bump and superficial cut to the nose with minimal bleeding. The COC did not indicate that a 1:1 sitter was present or that the fall was witnessed. Interviews with CNAs, the MDS Coordinator, and the DON confirmed that the resident had an order for continuous 1:1 monitoring, that no sitter was present at the end of the night shift, that the fall was unwitnessed, and that the physician’s orders and care plan for 1:1 supervision were not followed. The facility’s policy required targeted interventions, including adequate supervision, to be implemented correctly and consistently, which did not occur in this case.
Failure to Coordinate Dialysis Transportation Leading to Prolonged Post-Treatment Waits
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate coordination of transportation for a resident who required thrice-weekly hemodialysis. The resident, who had end stage renal disease requiring dialysis, hypertension, and a history of repeated falls, was admitted and re-admitted to the facility and was cognitively able to express needs and understand information. The resident used a walker or wheelchair and required substantial/maximal assistance with several ADLs. Documentation from the hemodialysis flowsheet showed that on 1/7/2026, the resident’s dialysis treatment ran from 10:48 a.m. to 2:56 p.m., but an Uber receipt from the hemodialysis center indicated the resident was not picked up until 5:29 p.m. and did not arrive back at the facility until 6 p.m. A hemodialysis social worker note stated that on that date the resident experienced long wait times after treatment, was not picked up by the arranged transportation, and the hemodialysis administrator had to assist with arranging Uber transportation back to the facility. Interviews and record review showed that the facility’s social services did not ensure that transportation pick-up times from the hemodialysis center were properly arranged or communicated. The Social Services Director (SSD) reported that the resident had ongoing problems with dialysis transportation related to insurance, including transportation arriving too early while the resident was still receiving treatment, but the SSD could not provide documentation of follow-up with the transportation agency. The resident reported that transportation during dialysis days often arrived too early, too late, or not at all, and stated he had waited three hours after dialysis for pick-up, feeling tired, weak, hungry, and ignored. The hemodialysis social worker indicated the problem could be that the facility did not inform transportation to arrange a pick-up time aligned with the end of treatment. Review of a document containing the resident’s insurance, dialysis schedule, and transportation information showed it listed only the pick-up time from the facility to the dialysis center and did not include a return pick-up time from the dialysis center. The SSD acknowledged that the flyer lacked a return pick-up time and that waiting for late or unarranged transportation would not make the resident feel good. The facility’s transportation policy stated that social services should help residents arrange needed transportation and that transportation concerns should be referred to social services.
Failure to Complete Weekly Skin Assessments for Resident with MASD
Penalty
Summary
The facility failed to follow its policy and procedure regarding skin breakdown by not performing weekly skin progress reports for a resident with moisture-associated skin damage (MASD). The resident had multiple risk factors, including diabetes mellitus, generalized muscle weakness, immobility, incontinence, and a history of candidiasis, all of which increased the likelihood of skin breakdown and infection. Documentation showed that the resident was dependent for personal hygiene and had documented skin impairment, with a care plan in place to resolve skin damage and reduce infection risk through regular skin assessments and weekly body checks. Despite these interventions being outlined in the care plan and facility policies, licensed nurses did not complete the required weekly skin assessments or progress reports for the resident during the specified month. Interviews with the treatment nurse and DON confirmed that weekly assessments were not performed, and the facility's policies required such monitoring and documentation. The lack of weekly assessments meant that the resident's MASD was not regularly evaluated for changes or response to treatment, as required by facility policy.
Failure to Implement Post-Fall Care Plan and IDT Review
Penalty
Summary
The facility failed to implement its policy and procedure for comprehensive, person-centered care planning following a resident's fall. After a non-verbal, bedbound resident with multiple diagnoses, including right knee osteoarthritis, hypertension, and ataxia, slid out of a wheelchair and onto the floor, the facility did not conduct an Interdisciplinary Team (IDT) meeting or document a post-fall care plan. The resident was identified as high risk for falls, and the facility's policy required measurable objectives and timetables to be developed and implemented after such incidents. However, there was no evidence of an IDT meeting or updated care plan in the resident's records after the initial fall. Subsequently, the same resident experienced another fall, sliding out of bed and onto the floor. Staff returned the resident to bed without notifying the charge nurse or supervisor and without a qualified staff member assessing for injuries. This resulted in the resident sustaining a fractured femur, enduring hours of pain, and requiring transfer to a general acute care hospital. Interviews with facility staff confirmed that required documentation and care planning were not completed after the initial fall, and the lack of these actions may have jeopardized the resident's safety.
Failure to Assess Pain After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with right knee osteoarthritis, hypertension, and ataxia was not assessed for pain following a fall. The resident, who had cognitive impairment and required substantial assistance with daily activities, was found on the floor by a CNA after a loud noise was heard. The CNA, noting the resident was nonverbal but nodded to indicate she was okay, did not notify the Charge Nurse of the fall due to nervousness and the presence of a recertification survey. Instead, the CNA returned the resident to bed and monitored for pain or discomfort without further assessment. A review of the resident's records indicated that, during a change of condition assessment, the resident exhibited facial grimacing and right leg pain when moved, but was unable to verbalize pain. The facility's policy required that all incidents or accidents be reported to the Charge Nurse and documented immediately, with the Charge Nurse responsible for the completeness and accuracy of the report. However, this protocol was not followed, resulting in a delay in pain assessment and intervention for the resident.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in incorrect data being transmitted to CMS. For one resident with diagnoses including paranoid schizophrenia and psychosis, the MDS did not reflect the administration of risperidone, an anti-psychotic medication, despite physician orders and documentation indicating its use. The MDS nurse confirmed that the anti-psychotic drug section was not properly marked, which was inconsistent with the resident's medication records. Another resident, diagnosed with congestive heart failure, anemia, and psychosis, experienced significant weight loss over a one-month period, as documented in the weights and vitals summary. However, the MDS assessment failed to code this weight loss under the appropriate section, despite clear evidence from the resident's records. The MDS nurse acknowledged the error, noting that the assessment should have indicated the resident was on a physician-prescribed weight-loss regimen due to the documented weight loss. A third resident, with diagnoses including hypertension, schizoaffective disorder, and atrial fibrillation, was prescribed Dabigatran Etexilate Mesylate, an anti-coagulant, as indicated in the order summary and care plan. The MDS assessment, however, did not document the use of this anti-coagulant. The MDS nurse confirmed that the medication should have been coded accordingly. Facility policies reviewed indicated that staff completing any portion of the MDS are required to certify the accuracy of the information provided.
Resident's Right to Smoke Restricted Against Policy
Penalty
Summary
A deficiency was identified when the facility failed to honor a resident's right to self-determination regarding smoking preferences. The resident, who was admitted with cellulitis of the right lower limb, sepsis, bacteremia, and an open wound to the right thigh, was found to be cognitively intact and required substantial assistance with activities of daily living. Despite this, the resident reported being limited to smoking only one cigarette per day at a designated time, as directed by the DON, rather than being allowed to smoke at her own preference. The resident expressed frustration and anger over this restriction. The DON confirmed that the limitation was imposed due to the resident's medical condition upon admission, specifically her weakness and wounds, and stated that the restriction would remain until her wounds began to heal. The facility's policy on resident rights, however, guarantees the right to exercise personal preferences, including smoking. The survey found that this practice resulted in a violation of the resident's rights as outlined in the facility's policy and federal and state regulations.
Failure to Obtain Informed Consent and IDT Review Before Initiating Psychotropic Medication
Penalty
Summary
The facility failed to obtain written informed consent and conduct an interdisciplinary team (IDT) meeting prior to initiating psychotropic medications for a resident diagnosed with dementia, bipolar disorder, and schizophrenia. The resident was determined to lack capacity to make decisions, as documented in the history and physical and the Minimum Data Assessment, which indicated severely impaired cognitive skills and total dependence on staff for daily care. Despite this, the resident was started on Depakote and risperidone based on physician telephone orders, and these medications were administered as documented in the medication administration records. During review, the Director of Nursing confirmed that informed consent forms for the psychotropic medications were not signed by the IDT and that no IDT meeting minutes were completed before the medications were initiated. The facility's policy required an IDT review and a bioethics meeting involving the resident's physician, another physician, and the IDT prior to administering psychoactive medications to residents lacking capacity, except in emergencies. These steps were not followed in this case.
Broken Curtain Rod Compromises Resident Privacy and Safety
Penalty
Summary
A deficiency was identified when a resident's room was found to have curtains hanging from a bent curtain rod, which had been in disrepair for some time. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, reported feeling violated due to the lack of privacy, as people outside could see into the room. The observation was made during a concurrent interview and inspection, confirming the ongoing issue with the room's curtains and curtain rod. The Maintenance Supervisor acknowledged responsibility for repairing equipment and furnishings and confirmed that the curtain and curtain rod in the resident's room were not in good condition and did not promote a homelike environment. The facility's policy on maintaining a homelike environment was reviewed, which emphasized the importance of staff and management maximizing characteristics that reflect a personalized, homelike setting. The deficiency resulted in a violation of the resident's right to privacy and a potential safety hazard.
Failure to Provide Timely ROM Assessments and Daily PROM Services
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for two residents with limited ROM. For one resident with diagnoses including bipolar disorder, dementia, and mobility abnormalities, the facility did not complete timely quarterly Joint Mobility Screenings/Assessments as required. The last assessment was completed at admission, and subsequent quarterly screenings were missed, which are necessary to monitor changes in ROM and determine if therapy services are needed. This omission was confirmed by both the Minimum Data Set Nurse and the Director of Rehab, who acknowledged that the screenings were not performed according to schedule. For another resident with diagnoses including dysphagia, seizures, and hemiplegia, the facility failed to ensure that passive range of motion (PROM) exercises were provided daily as ordered by the physician. Review of the RNA task forms showed that PROM was not performed every day, despite a physician's order for daily exercises. Both the Licensed Vocational Nurse and the Restorative Nurse Assistant confirmed that PROM was not completed as required, and acknowledged the importance of these exercises in preventing contractures and maintaining function. Facility policies and procedures reviewed indicated that residents with limited ROM should receive regular assessments and services to prevent further decline. The job description for the Restorative Nurse Assistant also specified the responsibility to assist residents with ROM exercises as ordered. The failure to follow these protocols resulted in missed opportunities to monitor and maintain the residents' joint mobility.
Failure to Remove Peripheral IV Catheter After Completion of Therapy
Penalty
Summary
A peripheral intravenous (IV) catheter was not removed from a resident after the completion of IV antibiotic therapy. The resident, who had diagnoses including urinary tract infection, dementia, and type 2 diabetes mellitus, was severely cognitively impaired and totally dependent on staff for daily care. According to the resident's medication administration records, the last dose of IV ceftriaxone was administered on 6/1/2025 at 4:30 p.m. On 6/3/2025, during an observation and interview, it was noted that the resident still had an IV line in place on the left hand, despite the antibiotic therapy having ended two days prior. The Minimum Data Set Nurse confirmed that the IV should have been removed immediately after the last dose, as per facility policy, which states that peripheral catheters are to be removed at the completion of therapy.
Failure to Accurately Account for and Document Controlled Drug
Penalty
Summary
The facility failed to ensure accurate accounting and documentation of a controlled drug, Lyrica, for one resident. The resident, who had diagnoses including hypertension, seizure disorder, and hemiplegia, was admitted with the capacity to make decisions and required moderate assistance with daily activities. Upon review, discrepancies were found in the documentation and physical count of Lyrica pills. The Controlled Medication Destruction Log indicated that 28 pills were turned in for destruction, but there was no signature to confirm receipt. The Director of Nursing (DON) did not sign the form due to an incorrect drug count, and the medication bubble pack showed 28 pills remaining, while the controlled drug record form indicated 30 pills. The DON stated that the nurse administered doses without documenting them and that proper handoff and drug count procedures during shift changes were not followed. Further review and interviews confirmed that the documentation did not accurately reflect the location or disposition of the controlled drug, and the process for destruction and reconciliation was incomplete. Facility policies required that controlled substances be reconciled at various points, including administration and shift changes, and that both the administering nurse and a witness sign off on the destruction of medications. The Licensed Vocational Nurse job description also required timely and accurate documentation of medication administration, which was not adhered to in this instance.
Failure to Act on Pharmacist's Recommendation for Medication Monitoring
Penalty
Summary
The facility failed to ensure that a consultant pharmacist's recommendation to consider ordering valproic acid and ammonia levels for a resident was acknowledged and acted upon. The resident in question had diagnoses including congestive heart failure, anemia, and psychosis, and was prescribed Depakote Delayed Release for mood disorder. The consultant pharmacist documented a recommendation in the Medication Regimen Review for the physician to consider ordering these laboratory tests to monitor the therapeutic blood level of the medication. However, the facility did not inform the resident's physician of this recommendation, and no orders for the tests were placed. The Director of Nursing confirmed that the facility's policy requires pharmacy consultant recommendations to be addressed within 14 days and that the purpose of the recommended tests was to ensure the medication was safe to administer. The facility's policy also states that recommendations should be acted upon and documented by staff or the prescriber, with the physician either accepting and acting on the suggestion or providing an explanation for disagreement. In this case, there was no documentation of action or physician response regarding the pharmacist's recommendation.
Failure to Complete Ordered Monthly Ammonia Level Lab Tests
Penalty
Summary
The facility failed to ensure that a laboratory test to check ammonia levels was completed monthly as ordered by the physician for one resident. The resident, who was admitted with diagnoses including bipolar disorder, dementia, and gait abnormalities, was determined to lack the mental capacity to make decisions and had severely impaired cognitive skills, requiring substantial assistance with daily activities. A physician's telephone order was placed for monthly ammonia level checks, but a review of the clinical records revealed that these tests were not completed for the months of March, April, and May. There was no documentation of the laboratory results for these months, and the Minimum Data Set Nurse confirmed that the tests had not been performed and results were unavailable. The facility's policy required staff to process test requisitions and arrange for laboratory tests as ordered by the physician. However, the required monthly ammonia level tests were not conducted, and there was no evidence in the records to indicate that the orders were followed. The Minimum Data Set Nurse acknowledged the omission and stated the importance of monitoring ammonia levels for the resident's medical management.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
A deficiency occurred when staff failed to implement enhanced barrier precautions (EBP) during the care of a resident with a feeding tube. The resident, who had diagnoses including hypertension, dysphagia, and malnutrition, was dependent on staff for activities of daily living and was identified as being at moderate risk for infection related to his feeding tube. The resident's care plan and facility policy both required the use of gloves and a gown when providing care involving the feeding tube. During an observation, a Licensed Vocational Nurse (LVN) was seen applying gloves but not a gown while checking the resident's feeding tube residual. The EBP signage at the resident's room and bed clearly indicated the need for both gloves and a gown. In an interview, the LVN acknowledged that EBP should have been followed and admitted to forgetting to wear a gown, which she recognized put the resident at risk for infection. The facility's policy confirmed that gown and gloves are required for such care activities.
Failure to Keep Dumpster Lids Closed
Penalty
Summary
During an observation with the Dietary Supervisor, one of two trash dumpster lids was found open and filled with trash. The Dietary Supervisor confirmed that all dumpsters were supposed to remain closed and acknowledged that leaving the lid open could lead to pest and vermin infestation. A review of the facility's waste control and disposal policy indicated that trash bins should be covered at all times.
Failure to Prevent Resident-on-Resident Physical Abuse Due to Inadequate Implementation of Abuse Policy
Penalty
Summary
The facility failed to implement its policy and procedure regarding the identification and prevention of abuse, resulting in a serious incident involving two residents. One resident, with a history of hypertension, bilateral hearing loss, type 2 diabetes, and hypercalcemia, and who was cognitively intact but required assistance with activities of daily living, was physically assaulted by another resident. The assault occurred after staff heard a loud noise and discovered the resident on the floor, being kicked and stomped on the head by another resident. The injured resident sustained significant injuries, including swelling to the forehead, a suspected zygomatic arch fracture, traumatic injury to the right ear and temple, temporary unconsciousness, and bleeding, necessitating transfer to an acute care hospital for treatment and subsequent readmission to the facility. The resident who committed the assault had diagnoses including paranoid schizophrenia, mood affective disorder, hypertension, and type 2 diabetes, and was noted to have severely impaired cognitive skills but was independent with activities of daily living. This resident had a care plan addressing non-compliance with treatment, specifically refusal of prescribed antipsychotic medication (Haldol), which was documented as refused daily for over two weeks prior to the incident. Staff interviews confirmed that the resident's refusal of medication was known and that the risk of aggression due to non-compliance was recognized, yet the facility did not take effective action to mitigate this risk or prevent the assault. The facility's policy, which strictly prohibits any form of resident abuse, was not effectively implemented in this case. Staff were aware of the resident's escalating paranoia, delusions, and refusal of antipsychotic medication, but failed to prevent the resulting physical abuse. The incident was directly observed by multiple staff members, who confirmed the sequence of events and the severity of the injuries sustained by the assaulted resident.
Failure to Implement Care Plan for Non-Compliant Resident
Penalty
Summary
The facility failed to implement a care plan for a resident who was non-compliant with medication, specifically Lithium Carbonate prescribed for paranoid schizophrenia. The resident had a history of refusing medications for two months, and the care plan required an Interdisciplinary Team (IDT) meeting to address this non-compliance. Despite the care plan's directive, the facility did not conduct an IDT meeting, nor did they document the resident's response to non-compliance or notify the physician of the medication refusals on specific dates. The resident, diagnosed with schizophrenia, suicidal ideations, and restlessness, was admitted to the facility with a history of non-compliance. The resident refused medication on multiple occasions, and progress notes indicated episodes of distress and refusal to take psychiatric medications. The Director of Nursing acknowledged that an IDT meeting should have been conducted due to the resident's non-compliance. The facility's policy required IDT involvement to address refusals, but this was not followed, resulting in the resident's continued refusal of medication not being addressed.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement its policy and procedure titled 'Work Practices,' which indicated that drinks should not be stored in areas of possible contamination. During an observation, a Licensed Vocational Nurse (LVN) was seen reviewing the computer screen on the medication cart while drinking cranberry juice. In a subsequent observation and interview, the same LVN was observed with a cup of cranberry juice and her personal cell phone ringing on top of the medication cart. The LVN acknowledged that both the juice and cell phone belonged to her and admitted awareness that she should not be drinking cranberry juice or placing her personal cell phone on the medication cart due to the risk of germ spread and potential illness. The facility's policy, dated April 2023, clearly stated that food and drink should not be stored in areas with possible contamination.
Lack of ADL Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident had a care plan for Activities of Daily Living (ADL) specific to showering, which included necessary interventions. This deficiency was identified during a review of the resident's records and interviews with staff. The resident, who was admitted with diagnoses including schizoaffective disorder, restlessness, lack of coordination, and abnormalities of gait/mobility, required supervision for showers, dressing, and personal hygiene as indicated in the Minimum Data Set (MDS). However, on a shower day, a Certified Nursing Assistant (CNA) allowed the resident to shower without direct supervision, resulting in the resident falling and sustaining an injury. The Director of Nursing (DON) confirmed that the resident should have had a care plan detailing the required supervision during showering. The facility's policies and procedures mandate the development of a comprehensive person-centered care plan with measurable objectives and timetables to meet the resident's needs. The lack of a specific care plan for showering supervision led to the resident not receiving the necessary care, contributing to the fall incident.
Failure to Protect and Account for Residents' Personal Belongings
Penalty
Summary
The facility failed to ensure the protection and accountability of personal belongings for two residents, leading to a deficiency in maintaining a safe and homelike environment. Resident 1's identification card, Medi-Cal card, and passport were not documented on the resident's Inventory List, despite being submitted to the Social Services Director (SSD) by the resident's brother. The Business Office Manager (BOM) claimed not to have received these items, and the SSD admitted to not updating the Inventory List. This oversight resulted in the resident's personal documents being unaccounted for when the resident's representative received an envelope missing these items. Additionally, the facility did not prevent the loss or theft of Resident 3's personal belongings, specifically 20 Compact Discs (CDs) and a CD player. Resident 3, who is blind, reported the loss of her Bible CDs to the SSD and an unnamed supervisor, but the issue was not addressed. The Director of Nursing (DON) was unaware of the missing CDs and acknowledged the importance of these items for Resident 3's well-being due to her visual impairment. The facility's Policy and Procedure on Personal Property, which mandates the inventory and documentation of residents' belongings upon admission and as necessary, was not followed. The policy also requires prompt investigation of any complaints regarding misappropriation or mistreatment of resident property, which was not conducted in these cases. This failure to adhere to established procedures contributed to the deficiency in safeguarding residents' personal belongings.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for oxygen administration, which led to the resident receiving oxygen without proper authorization. The resident, who had a history of complex medical conditions including metabolic encephalopathy, sepsis, pneumonitis, diabetes mellitus, anemia, hypertension, chronic systolic heart failure, bacteremia, kidney failure, and adult failure to thrive, was admitted without an order for oxygen. On a specific date, the resident experienced low oxygen saturation levels of 79%-81% while on 2 liters of oxygen per minute, yet the physician was not notified to obtain the necessary orders for oxygen administration. The Licensed Vocational Nurse (LVN) on duty did not follow the facility's policy to notify the physician of the resident's change in condition, as indicated in the care plan. The Director of Nursing (DON) confirmed that the care plan required prompt notification of the medical doctor for respiratory distress symptoms, which was not done. The facility's policy and procedure for changes in a resident's condition and oxygen administration were not adhered to, resulting in a delay in receiving appropriate interventions from the physician, ultimately leading to the resident's transfer to a general acute care hospital.
Incomplete Clinical Records for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, which is necessary for providing appropriate care. The resident was admitted with multiple diagnoses, including metabolic encephalopathy, sepsis, pneumonitis, diabetes mellitus, anemia, hypertension, chronic systolic heart failure, bacteremia, kidney failure, and adult failure to thrive. A discrepancy was noted between the resident's History and Physical (H&P) and the Minimum Data Set (MDS) regarding the resident's cognitive ability and decision-making capacity. The H&P did not indicate the resident's capacity to understand and make decisions, while the MDS showed impaired cognitive ability and dependence on staff for activities of daily living and mobility. On a specific date, the resident experienced shortness of breath, and vital signs were taken but not documented in the progress notes by the Licensed Vocational Nurse (LVN). The Director of Nursing (DON) confirmed that the progress notes were incomplete, lacking a thorough account of the assessment, interventions, and physician notification of the change in the resident's condition. The facility's policy and procedure for changes in a resident's condition or status required detailed observations and documentation, which were not followed in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three residents, leading to a potential delay in obtaining necessary care. Resident 65 was observed in his room, unable to reach his call light, which was tied to the nightstand. Despite being awake and alert, Resident 65 had to resort to pressing the TV remote control and shouting for help. The resident's medical history included cerebral infarction, contracture of the left hand, and major depression, and he was dependent on staff for activities of daily living. A CNA admitted to forgetting to check the call light during rounds, acknowledging the risk of falls if the call light was not accessible. In another instance, the call lights for two residents, Resident 43 and Resident 72, were found clipped to a string on the overhead light above their beds, out of reach. Resident 43 had a history of type 2 diabetes, anxiety disorder, and schizophrenia, and required supervision for daily activities. Resident 72 had dementia, anxiety disorder, and chronic kidney disease, and also required assistance for daily living activities. A CNA confirmed that the call lights should not have been placed on the overhead light cord and emphasized the importance of having them within reach for emergencies. The Director of Nursing confirmed that call lights should always be within reach to prevent potential harm to residents. The facility's policy on call lights stated that staff should ensure call lights are accessible to residents in their rooms or when on the toilet. The failure to adhere to this policy resulted in a deficiency that could have delayed necessary care and services for the affected residents.
Failure to Conduct Yearly Competency Assessments for CNAs
Penalty
Summary
The facility failed to ensure that competency assessment skills were performed yearly for three out of five randomly selected Certified Nursing Assistants (CNAs). During an interview and record review with the Director of Staff Development (DSD), it was found that CNAs 2, 3, and 5 did not have their competency assessments completed on an annual basis. The DSD acknowledged that these assessments should be conducted upon hire and then yearly, and she was responsible for completing them. The lack of these assessments could potentially jeopardize resident health and safety, as it would prevent the facility from assessing the necessary skills to provide nursing services. The Director of Nursing (DON) confirmed that all nursing staff should have current competency assessments to ensure they can provide the standard of care and practice within regulations. The facility's policy and procedure, titled 'Sufficient and Competent Nursing Staffing,' revised in August 2022, indicated that the facility is required to provide sufficient numbers of nursing staff with the appropriate skills and competency necessary to care for all residents in accordance with their care plans and the facility assessment. The failure to perform these assessments as per policy could lead to a deficiency in providing adequate care to residents.
Deficiencies in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, as well as maintaining cleanliness in the kitchen area. During an observation, three tubs of ice cream in Freezer #5 were found without received-by and delivery dates. This oversight was confirmed by Dietary staff, who acknowledged that the tubs should have been dated to prevent the risk of serving expired food, which could potentially cause illness among residents. The Dietary Supervisor also confirmed that all food items should be labeled with appropriate dates to avoid possible contamination and foodborne illnesses. Additionally, a dirty apron bin was observed in the dry storage area of the kitchen, which is against the facility's policy. The presence of the dirty apron bin in the dry storage area was acknowledged by the Dietary staff and the Dietary Supervisor, who stated that it could lead to contamination of food items stored in that area. The facility's policy requires that storage areas be clean, dry, and well-ventilated, and that all items in refrigerators and freezers be properly covered, dated, and labeled.
Failure to Implement Infection Control Measures for Residents on Enhanced Standard Precautions
Penalty
Summary
The facility failed to implement proper infection control measures for two residents, identified as Residents 15 and 24, who were on Enhanced Standard Precautions (ESP) due to their use of gastrostomy tubes (g-tubes). Staff did not wear the required Personal Protective Equipment (PPE), specifically gowns, when administering medication via g-tube to these residents. This oversight was observed during a survey, and it was noted that the lack of PPE use could lead to cross-contamination and the spread of infections, putting other residents at risk. Resident 15 had a history of peripheral vascular disease, type 2 diabetes mellitus, and heart failure, and was assessed to rarely or never understand others, being dependent on staff for activities of daily living. Similarly, Resident 24 had diagnoses including cerebral infarction, acute kidney failure, and type 2 diabetes mellitus, and was also assessed to rarely or never understand others, requiring staff assistance for daily activities. Both residents were on ESP due to their g-tubes, and the facility's policy required the use of gowns and gloves during high-contact care activities, which was not adhered to by the staff.
Failure to Regularly Evaluate and Reduce Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 69, was free from the use of physical restraints unless necessary for medical treatment. Resident 69, who was admitted with Alzheimer's disease and a seizure disorder, was observed using a lap buddy restraint in a wheelchair. The resident's cognitive skills were severely impaired, and the restraint was reportedly used for safety due to involuntary movements. However, the facility did not conduct regular evaluations or attempt less restrictive measures as required. The last physical restraint assessment for Resident 69 was conducted several months prior, and no ongoing quarterly assessments were performed. During interviews, staff members, including an LVN and the MDS coordinator, acknowledged the lack of regular assessments and attempts to use less restrictive devices. The facility's policy required the interdisciplinary team to evaluate restraint measures and make recommendations, but this process was not followed. The Director of Nursing confirmed that physical restraints should not be permanent and should be reassessed frequently. The failure to conduct regular evaluations and explore less restrictive options placed Resident 69 at risk for unnecessary prolonged use of restraints.
Failure to Resubmit PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I screening was re-submitted for a resident after a hospital exemption, despite the resident staying in the facility for more than 30 days. This oversight was identified during an interview and record review, where it was noted that the resident, who had diagnoses including epilepsy, anxiety disorder, and schizophrenia, did not have the necessary PASRR Level II evaluation and determination completed. The resident was dependent on staff for activities of daily living, and the lack of a timely PASRR submission had the potential to impact the psychiatric level of treatment and evaluation the resident received. The Minimum Data Set (MDS) coordinator acknowledged that the PASRR should have been resubmitted on the 31st day of the resident's stay, as per the Department of Health Care Services Letter. The facility's policy indicated that a new Level I PASRR should be submitted if the pre-admission screening was exempted for fewer than 30 days and the resident remained at the facility longer than 30 days. The Director of Nursing confirmed that the PASRR is essential for assessing the services a resident may need. The failure to resubmit the PASRR was a deviation from the facility's policy and procedure, potentially affecting the resident's access to necessary services.
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 originally admitted and later readmitted to the facility, had a documented diagnosis of schizophrenia and dementia. Despite this, the PASRR Level 1 screening did not reflect the resident's schizophrenia diagnosis, leading to the case being closed without a Level 2 evaluation. This oversight was identified during a review of the resident's records and an interview with the Minimum Data Set (MDS) coordinator, who acknowledged the error in the screening process. The resident's medical records, including the History and Physical (H&P) and Minimum Data Set (MDS), indicated significant cognitive and functional impairments, such as total dependence in personal care activities. The facility's policy required a new Level 1 PASRR to be submitted in case of any discrepancies, but this was not done. The failure to correctly identify the resident's mental disorder in the PASRR Level 1 screening potentially prevented the resident from receiving appropriate treatment recommendations for schizophrenia.
Failure to Implement Bed Alarm for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as high risk for falls. The resident, who was admitted with Alzheimer's disease and a seizure disorder, had severely impaired cognitive skills and required maximum assistance for daily activities. The care plan for this resident included the use of a bed alarm to alert staff when the resident attempted to get up unassisted. However, during an observation, the resident was found trying to get out of bed without a bed alarm in place, despite being on a low bed with side rails and a floor mat. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the bed alarm intervention was not implemented. The DON was unaware of the care plan requirement for a bed alarm, and the LVN confirmed that the resident was found on the floor mat without the alarm. The facility's policy on personal alarms and managing falls indicated that sensor pads should be used to alert staff to potential falls, but this was not followed for the resident in question.
Improper Storage and Use of Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident by not dating and properly storing a nasal cannula used for oxygen therapy. During an observation, an oxygen concentrator and nasal cannula were found at the resident's bedside, with the concentrator turned off and the nasal cannula undated and uncovered, exposing it to potential contamination. The Licensed Vocational Nurse (LVN) confirmed that the nasal cannula was not dated and lacked a protective covering, which is necessary to prevent contamination from room air. Additionally, the resident did not have a physician's order for oxygen therapy, which is required to administer oxygen safely. The Director of Nursing (DON) confirmed that a physician's order is necessary and that oxygen tubing should be dated and stored in a plastic bag with a label when not in use. The facility's policy on oxygen administration did not specify the need for covering oxygen tubing when not in use, contributing to the oversight.
Failure to Document Resident's Refusal of Splints
Penalty
Summary
The facility failed to document a resident's refusal to wear prescribed splints, which are external devices used to support and immobilize injuries or joints. This deficiency was identified through observation, interview, and record review. The resident, who was admitted with diagnoses including cerebral infarction and contracture of the left hand, was observed without the splints on multiple occasions. The resident's Minimum Data Set indicated dependency on staff for various activities and noted the provision of passive range of motion and splint assistance. However, the Restorative Nurse Assistant (RNA) admitted to not documenting the resident's refusal to wear the splints, which was a requirement per the facility's policy. The RNA stated that the splints were stored in the resident's drawer and acknowledged forgetting to document the refusal weekly. The Licensed Vocational Nurse (LVN) was unaware of the resident's refusal, and the Director of Nursing (DON) confirmed that the RNA should have documented the refusal and reported it to the charge nurse. A review of the facility's policy on charting and documentation emphasized the need for complete and accurate records, including details of procedures and treatments. The lack of documentation regarding the resident's refusal to wear the splints was a clear deviation from these standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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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) |
|---|---|---|---|---|
| St Andrews | 0.6 mi | ★★★★★ | 0 | 0 |
| East Terrace Rehabilitation & Wellness Centre, Lp | 0.7 mi | ★★★★★ | 29 | 0 |
| St. John Of God Retirement | 0.7 mi | ★★★★★ | 32 | 0 |
| Sunray Healthcare Center | 0.8 mi | — | 32 | 2 |
| The Rehabilitation Center On Pico | 0.8 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.