Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Grove Post-acute during CMS and state inspections, most recent first.
Food service sanitation standards were not maintained in the kitchen and storage areas. Surveyors found unlabeled and undated food in the freezer and refrigerator, spoiled bananas in dry storage, cracked spice lids with residue, dirty trash bin lids, a soiled can opener, sticky residue on refrigerator shelves and juice dispenser parts, dust and debris on stored pots and pans, worn baking sheets with rust-like staining, a dirty hood range, soiled wiping cloths on the food prep area, dirty and worn dish racks, and contaminated dry goods bins. The DNS, DDN, and RD confirmed the findings and stated the items should be clean, labeled, dated, and sanitary.
Staff failed to follow infection control practices during EBP and laundry handling, including removing PPE in the hallway, reusing a cotton gown after it touched a trash can, handling clean laundry after soiled laundry without changing clothing, and not performing hand hygiene after contaminated contact. In the kitchen, the CK handled tray-line service with the same gloves while touching clothing, tray-line surfaces, and moving trays, and used an apron to wipe food from her gloves without changing them. The outside dumpster was uncovered, had no functional lid, and flies were observed around garbage inside the dumpster.
A resident with kidney disease and moderate cognitive impairment was found in a room that felt cold, with multiple blankets in use and a towel placed over the floor vent to block cold air. Staff said the unit was usually cold, residents had complained, and the MD did not have a routine for checking room temperatures. When the MD checked the room, temperatures were below the facility’s 71°F to 81°F comfort range.
A resident with alcoholic hepatitis, a cognitive communication deficit, and homelessness was discharged without a discharge plan while Medi-Cal was still pending. Records showed no active community discharge plan, the IDT could not secure a PCP because of pending insurance, and SS could not provide documentation of ongoing discharge planning. The HHA reported receiving inconsistent discharge addresses and was not told that Medi-Cal was pending, and said the resident would not qualify for HH RN services with the insurance information provided.
Two of nine sampled CNA personnel files were missing current annual Abuse Prevention and DOJ training records. During a record review with the DSD, CNA files showed that two CNAs did not have 2025 training documented, while the remaining sampled records were current or current at the time of review. The DSD confirmed the trainings are required annually, and the facility policy required staff training on abuse prevention, identification, and reporting of abuse.
A cognitively intact resident who had long occupied a room reported that a new roommate repeatedly cursed at her, kept the TV excessively loud, and on one occasion called her a derogatory slur, making her feel less than a person. Staff, including an LPN and the MDS nurse, were aware of ongoing conflicts and acknowledged that the language used could constitute verbal abuse, and a family grievance documented the abusive remark and requested a room change for the aggressor. The facility’s abuse policy defined verbal abuse as disparaging or derogatory language toward residents regardless of comprehension and required removal of a resident who threatened or attacked another, yet the Administrator declined to treat the incident as an allegation of verbal abuse, citing lack of intent, which is not supported by the written policy.
Two cognitively intact residents sharing a room had ongoing conflicts, with one resident reporting that the other cursed at her daily and called her a derogatory slur, which was documented by an LPN and reported by a family member through a grievance. The SSD and MDS nurse were aware of the incident, and the MDS nurse believed the cursing constituted abuse and ensured management was notified. Despite an abuse policy defining verbal abuse as willful use of disparaging and derogatory language and requiring prompt reporting of patient-to-patient abuse to state authorities, the administrator, acting as abuse coordinator, decided the incident was not an allegation of verbal abuse based on his belief that there was no intent, and the incident was not reported to the state as required.
A resident with dementia shoved a walker into another resident's legs during an argument, causing a skin tear and bruising to the left knee. The incident was witnessed by a CNA and confirmed by nursing assessment, with documentation showing the injury required dressing changes. The facility's abuse prevention policy prohibits such abuse between residents.
The facility failed to maintain sanitary conditions in the kitchen, with a used cookie wrapper and an open thickener container found in the dry storage area. Additionally, expired diced apples and boiled eggs were discovered in the walk-in refrigerator. The Dietary Manager confirmed these unsanitary conditions and expired items, which were not in compliance with the facility's policy and the US FDA 2022 Food Code.
The facility failed to ensure call lights were accessible and functional for three residents, posing a safety risk. A resident with moderate cognitive impairment had a call light out of reach and without a button, while another severely impaired resident's call light was similarly inaccessible. A third resident's call light was obscured and unreachable. Staff confirmed these issues, but they were not reported for maintenance as required by facility policy.
A facility failed to notify the responsible party of a resident's transfer to an acute care hospital, as required by policy. The resident, with severe cognitive impairment due to memory deficit and dementia, was sent to the ER for disturbing behaviors. The Director of Nursing confirmed the lack of notification, which is against the facility's policy requiring documentation of such notices.
A facility failed to submit a resident's MDS within the required timeframe. The resident's discharge assessment was completed and transmitted more than 14 days after discharge, contrary to the facility's policy and federal requirements. The MDS Coordinator confirmed the delay, and the DON expected adherence to submission timeframes.
A facility failed to complete a required PASARR for a resident admitted with Major Depressive Disorder. The resident's medical record indicated the need for a new Level 1 Screening if the stay exceeded 30 days, which was not done. The DON and Administrator confirmed the oversight during an interview, and no additional PASARR documentation or policy was provided upon request.
A LTC facility failed to adhere to professional standards of care for several residents. A nurse administered the wrong dosage of psyllium powder to a resident, while another resident's feeding tube became blocked due to improper medication administration. Additionally, a resident received another's insulin, and the order for compression socks was not followed. Another resident's catheter was not flushed as ordered, leading to sediment buildup. These actions indicate a failure to follow physician orders and facility policies.
A resident with vascular dementia, at risk for wandering, was not wearing a prescribed wander guard during multiple observations, despite an active order. The ADON confirmed the oversight, and the DON acknowledged the necessity of the device for the resident's safety. The facility's policy requires strategies for residents at risk of unsafe wandering.
A facility failed to communicate pharmacy recommendations to a physician for a resident with insomnia, who had multiple PRN orders for Melatonin. The Consultant Pharmacist recommended discontinuing one PRN order, but there was no documented evidence that the physician was informed. The DON confirmed the issue, but the MRD could not find documentation of communication, leading to a deficiency.
A facility experienced a medication error rate of 23.08% due to multiple administration errors. A nurse gave a resident the wrong dosage of psyllium powder, another resident received insulin from a different resident's supply, and a third resident's feeding tube was blocked after medications were improperly administered together. These incidents highlight failures in following prescribed orders and facility policies.
A resident with Type 1 Diabetes Mellitus received insulin from another resident's supply due to a nurse's failure to check the label properly. The nurse, in a hurry, administered 22 units of insulin glargine without verifying the correct supply, despite having undergone training in proper medication administration. The facility's policy requires verification of the right resident, medication, dose, time, and method before administration.
A resident with Type 1 Diabetes Mellitus had their insulin glargine order changed to 22 units daily, but the vial label still indicated 27 units. During a medication administration, a nurse confirmed the discrepancy. The ADON noted the label should have been updated to prevent errors, as per facility policy.
The facility failed to have written agreements for dialysis services for two residents with end-stage renal disease. Despite policy requirements, the facility did not secure a contract with the dialysis provider, as confirmed by the Administrator. This oversight could lead to a lack of accountability in the care provided.
The facility failed to maintain effective infection control, with deficiencies in PPE disposal for a resident on Enhanced Barrier Precautions, improper insulin administration without disinfecting the vial top, and overdue nebulizer tubing changes and improper storage of an incentive spirometer for another resident. These lapses increased infection transmission risks.
A resident experienced discomfort due to a shattered glass patio door covered with plastic in their room, which was not repaired despite requests. The maintenance log showed the issue was reported, but only a temporary fix was applied. An invoice for repair was found without a signed acceptance, and the facility's maintenance policy was not followed.
A resident with severe cognitive impairment and multiple fractures experienced a delay in the reporting of an injury of unknown origin. Despite the X-ray results indicating a fracture on June 22, the facility's management was not informed until June 24, contrary to the facility's policy requiring immediate reporting. This delay hindered the investigation process and reduced the facility's ability to protect the resident from harm.
A resident with severe cognitive impairment and aggressive behaviors was not accurately documented in the MDS, despite evidence of frequent physical aggression. Staff interviews confirmed the behaviors, but the MDS was improperly coded, potentially affecting the resident's care plan.
The facility failed to protect two residents from physical abuse when they were involved in an altercation, resulting in one resident sustaining a skin tear and bruising. The incident occurred over a disagreement about a balcony door, leading to both residents swinging their arms at each other. The altercation and resulting injuries were confirmed by both residents and documented in their medical records.
The facility failed to report an alleged physical abuse incident between two residents within the required two-hour timeframe. Both residents confirmed a physical altercation, but the incident was not reported to the Department immediately as per facility policy.
The facility failed to provide a safe and homelike environment. A resident's low air loss mattress was not in good working condition for five months, and five rooms had peeling paint and damaged drywall. Despite complaints, no maintenance reports were made.
A resident identified as a good candidate for bladder retraining did not receive the necessary interventions, leading to a decline in continence. Despite being initially continent and aware of the need to toilet, the resident became frequently incontinent due to the lack of a scheduled toileting program. Staff interviews and record reviews confirmed the absence of a bladder retraining program, contrary to the facility's policy.
The facility failed to replace used E-Kit boxes and did not administer IV antibiotics per physician's order for a resident with sepsis. The E-Kits were not replaced within the required 72 hours, and the resident did not receive the full dose of antibiotics as prescribed.
A resident with dementia was administered Seroquel without adequate indication for over six months. Despite no documented episodes of physical aggression, the resident continued to receive the medication without attempts at dose reduction or non-pharmacological interventions. Staff interviews and record reviews confirmed the lack of justification for the medication use.
The facility failed to properly store medications for 120 residents. Expired ertapenem intravenous medication bags were found in the medication refrigerator, and three loose pills were found in a medication cart. Additionally, two prescription blister packs were found displaced and stuck in the back of the medication cart. The DON confirmed that medication storage areas should be checked every shift and cleaned to ensure proper medication accounting.
The facility failed to prepare foods that conserved nutritive value, flavor, and palatability when a cook did not follow recipes or measure ingredients for stir fry vegetables and pureed meals. The Registered Dietitian confirmed that this practice could alter nutrition, and the facility's policy emphasized the importance of following specific recipes.
The facility failed to store, prepare, and distribute food safely, affecting 117 residents. Issues included improper food labeling, expired foods, unsafe food temperatures, ice build-up in the freezer, dirty kitchen areas, and improper thermometer use. These deficiencies were confirmed by the AD and DM, posing potential health hazards.
A resident with a history of falls and a right femur fracture did not receive the ordered physical therapy (PT) evaluation and treatment. Despite physician orders to start PT, the facility failed to provide the necessary services, and the resident's physician was not notified of the non-compliance. The lack of communication and documentation contributed to the deficiency.
The facility failed to follow infection prevention and control practices when a blood pressure monitor was not disinfected between uses and an exhaust fan above the clean linen area in the laundry room was found to be coated with a thick, sticky substance. These lapses were confirmed by staff and violated the facility's policies.
The facility failed to complete and transmit the discharge MDS assessment for a resident with essential hypertension within the required time frame. The MDS Coordinator confirmed that the assessment was missed and not completed on time, resulting in the most recent MDS resident assessment not being reported to CMS as required.
A facility failed to ensure the MDS for a resident accurately reflected the resident's POLST, leading to a discrepancy where the MDS indicated 'Attempt resuscitation / CPR' while the POLST indicated 'Do Not Attempt Resuscitation (DNR)'. This was confirmed by the MDSC and DON, highlighting a failure to correct the information during the MDS admission assessment.
The facility failed to refer a resident for a PASRR assessment after the resident received a new mental illness diagnosis. Despite being diagnosed with Schizoaffective disorder and Major Depressive disorder, the resident's PASRR Level I assessment from 2011 was not updated, and no referral for a PASRR Level II assessment was made. Interviews with staff confirmed the oversight, and the facility's policy requiring adherence to CMS guidelines was not followed.
The facility failed to develop a comprehensive care plan for a resident refusing nail care. Despite being cognitively intact and having long, dirty fingernails, the resident's refusals were reported but not documented or addressed in a care plan, contrary to facility policy.
A resident with hemiplegia and hemiparesis was observed with extremely long and dirty fingernails, despite being dependent on staff for personal hygiene. The resident had been refusing care, and the staff failed to document the refusals or create a care plan addressing the issue, leading to a deficiency in nail care.
The facility failed to provide adequate supervision and assistive devices for two residents, leading to falls. One resident fell while being assisted by a CNA who turned her back, and another resident fell from bed due to the absence of side rails and fall mats, despite physician orders and care plan interventions. Facility policies on resident safety and supervision were not followed.
The facility failed to provide sufficient fluids to a resident at risk for dehydration, who had severe cognitive impairment and was dependent on staff for hydration. Despite the Registered Dietitian's assessment of a daily fluid need of 1625 ml, the resident's average intake was only 874 ml. Observations and staff interviews confirmed inadequate assistance and monitoring, with the resident's water pitcher consistently placed out of reach and no documented evidence of water being offered at night.
A resident with COPD and respiratory failure received more oxygen than prescribed, as the oxygen concentrator was set at 3 L/min instead of the ordered 2 L/min. The facility's policy requires reviewing physician's orders and care plans to ensure proper oxygen flow, which was not followed, potentially causing harm to the resident.
The facility failed to properly dispose of garbage and refuse when one of the four covers of the garbage dumpster was found open during an observation with the Assistant Dietary Manager. The AD confirmed the dumpster should have been shut to prevent bacteria contamination, as per facility policy and the US FDA 2022 Food Code.
Food Storage and Kitchen Sanitation Failures
Penalty
Summary
The facility failed to maintain professional standards for food service safety in the kitchen and food storage areas. During observation with the Dietary and Nutrition Supervisor and the Director of Dietary and Nutrition, surveyors found unlabeled and undated food in the reach-in freezer and walk-in refrigerator, including brussels sprouts, beef strips, egg rolls, meatless meat balls, lima beans, wheat rolls, tofu, sliced turkey, fish cod fillet, sliced lettuce, and vanilla-flavored ice cream. Multiple spice containers had cracked lids with whitish-brownish dust-like substances, and spoiled bananas were present in the dry storage area. The Director of Dietary and Nutrition confirmed the findings and stated food should be dated, labeled, clean, and sanitary to prevent food spoilage, cross contamination, and foodborne illnesses. Additional kitchen observations showed two trash bin lids with scattered brownish sticky substances, a can opener blade with orange-colored substances, and the floor and metal shelves inside the walk-in refrigerator with brownish-blackish sticky substances. On a later observation, the juice dispenser spouts and connection tubing had scattered sticky-brownish substances, several pots and pans stored under a work table were exposed to dust and debris, multiple baking sheet pans were worn with rust-stained-like color on the inner rims, and the cooking hood range had dust-oil-like substances. The Director of Dietary and Nutrition confirmed these findings and stated that keeping equipment clean and organized was crucial for food safety and prevention of foodborne diseases and bacteria build-up. During a subsequent observation with the Registered Dietician, two soiled wiping cloths were left on top of the food preparation area, twelve dish racks were grayish-blackish sticky, chipped, old, and worn out, and six movable dry goods container bins and sidings had scattered fluid-like brownish and blackish substances. The Registered Dietician confirmed the findings and stated soiled cloths should be in a sanitized bucket, dirty dish racks can transfer bacteria and pathogens to clean items, and dirty dry goods bins can attract insects. The facility policy required kitchens, utensils, shelves, and equipment to be kept clean and in good repair, wiping cloths to be cleaned or placed in sanitizing solution, and food items in storerooms, refrigerators, and freezers to be labeled and dated.
Infection Control Failures During PPE Use, Laundry Handling, Food Service, and Waste Storage
Penalty
Summary
The facility failed to maintain infection prevention and control practices during enhanced barrier precaution use and laundry handling. During observation, a laundry staff member exited an EBP room wearing a blue PPE gown and removed the gown in the hallway, carrying it under the arm down the hallway. In the laundry room, the same staff member touched a dirty washer and then obtained clean gloves, placing the clean gloves into a back pocket. Another laundry staff member removed a reused cotton PPE gown after washing clothes, placed it on a hanger, allowed it to touch a trash can, and then placed the dirty gown in a holding area on a hook instead of discarding it. Hand hygiene was not performed after touching the gown, and the housekeeping supervisor acknowledged the staff did not perform hand hygiene after touching the washing equipment and that the reused gown had touched the trash. A separate observation in the laundry area showed a staff member handling clean laundry while wearing the same clothing worn earlier during soiled laundry handling. The infection prevention nurse stated staff were expected to remove gowns and gloves without touching contaminated surfaces and perform hand hygiene immediately, and stated PPE was not expected to be reused after handling dirty laundry. The nurse also stated reusing or touching contaminated PPE after exposure to soiled items could transfer pathogens to clean linens, equipment, and individuals. In the kitchen tray-line area, the CK handled food with gloved hands while repeatedly touching her clothing, the side rim of the service tray-line area, and moving trays parked nearby, and used her apron to remove food dripped on her gloves without changing gloves. The CK acknowledged all of the findings and stated she should have safely handled food during tray-line service to prevent cross contamination and germ transmission. The registered dietician stated the contaminated gloves should have been changed and discarded immediately. The outside dumpster side-mounted opening was also observed uncovered with no functional lid, garbage being dumped inside, and flies flying around the dumpster; the maintenance director confirmed these conditions and stated flies spread bacteria from garbage.
Cold Resident Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable room temperature for one sampled resident, Resident 57, whose room was below the facility’s stated comfortable range of 71°F to 81°F. Resident 57 was admitted with kidney disease and had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. During observation, Resident 57 was found in bed fully covered with multiple blankets and stated that the room always felt cold, that the issue had been discussed in resident council, and that she had not noticed any changes. She also pointed to a folded towel placed over the floor vent by staff to block cold air and stated she had shivering anxiety. Staff interviews confirmed the cold conditions on the unit and in residents’ rooms. CNA 14 and LN 16 stated the unit was usually cold, that they wore extra jackets, and that residents had complained about cold rooms; they also acknowledged towels had been placed over floor vents to reduce cold air flow. The Maintenance Director stated the building felt cold, that he had closed several windows on another unit, and that he did not have a routine for checking room temperatures. When he measured Resident 57’s room with a laser temperature gun, the mid-room and ceiling were 69°F and the floor was 67°F. Resident 57 stated she felt cold and was not very comfortable at that time.
Unsafe discharge without a plan or active insurance coverage
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for one resident who was discharged while a Medi-Cal application was still pending and without a discharge plan. The resident had been admitted with alcoholic hepatitis, a cognitive communication deficit, and homelessness. The initial discharge planning documentation identified the resident’s goal of returning to the community and noted concern about having no housing, and the psych provider later documented situational anxiety related to discharge planning and recommended continued supportive reassurance and coordination with Social Services. Later records showed there was no active discharge plan to return to the community, and an order indicated the resident may discharge home with HH RN services. The IDT discharge summary stated that due to insurance pending status, a primary care physician for transfer of care was unattainable. At the time of discharge, Social Services confirmed the resident was homeless and the Medi-Cal application was still pending, but could not provide documentation of ongoing discharge planning. The home health agency reported it received different discharge addresses, including one that only identified a city, and stated it was not informed that Medi-Cal was pending; based on the insurance information provided, the resident would not qualify for HH RN services.
CNA Annual Abuse Prevention and DOJ Training Records Were Not Current
Penalty
Summary
The facility failed to ensure that two of nine sampled CNA personnel records were current for annual Resident Abuse Prevention and Department of Justice (DOJ) training. During a concurrent interview and record review with the Director of Staff Development, the CNA personnel files were reviewed for completion of the annual Abuse Prevention and DOJ trainings. The review showed that CNA 1, hired 11/1/23, had no Abuse Prevention and DOJ training for 2025, and CNA 4, hired 9/4/24, also had no Abuse Prevention and DOJ training for 2025. The remaining sampled CNA records reviewed were documented as current or, for terminated employees, current at the time of review. During the interview, the Director of Staff Development confirmed that Abuse Prevention and DOJ trainings are conducted annually and that employees are expected to attend the trainings each year. The facility policy titled Abuse Prevention Program, revised 12/16, stated that the facility develops and implements policies and procedures to prevent abuse, neglect, or mistreatment of residents and requires staff training and orientation programs that include abuse prevention, identification, and reporting of abuse.
Failure to Protect Cognitively Intact Resident From Verbal Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from verbal abuse by a roommate. Resident 1’s MDS showed a BIMS score of 13, indicating intact cognition, and an active order documented that Resident 1 was capable of making her own health decisions. Over several weeks, Resident 1 reported that her roommate, Resident 2, kept the television too loud and cursed at her daily. Resident 1 stated that staff told her there was nothing they could do, that they could not force Resident 2 to move, and that Resident 1 could move if she did not get along with her roommate, despite Resident 1 having lived in the room for years without prior issues. Resident 1 reported feeling less than a person because staff would not move the roommate who was cursing at her and making her feel uncomfortable. On one specific occasion, Resident 1 reported to LN 1 that Resident 2 called her a derogatory slur (“f . c .”) the previous night, which LN 1 documented in the nurse’s notes. LN 1 acknowledged there had been ongoing issues between the two residents and stated that the words used by Resident 2 were not appropriate and could be considered verbal abuse. The MDS nurse also stated that the cursing by Resident 2 toward Resident 1 would constitute abuse and had LN 1 notify management of the incident through the facility’s charting system. Resident 2, when interviewed, expressed dislike for the current room and roommate and spoke in an aggressive tone. The Social Services Director confirmed awareness of ongoing roommate conflict, including a family report that the residents were not getting along and a grievance filed by Resident 1’s family member describing the incident where Resident 2 called Resident 1 the derogatory slur and requested a room change for Resident 2. The facility’s Abuse Prevention Policy defined verbal abuse as the use of disparaging and derogatory terms toward residents or their families, or within hearing distance, regardless of age, ability to comprehend, or disability, and required that if suspected abuse was patient-to-patient, the resident who threatened or attacked another would be removed from the setting. Despite this policy and staff statements that the behavior constituted abuse, the Administrator stated the incident was not considered an allegation of verbal abuse because he believed Resident 2 did not have intent, and he was unable to identify any reference to intent in the abuse policy. This failure to recognize and treat the incident as verbal abuse resulted in the facility not protecting Resident 1 from verbal abuse by Resident 2.
Failure to Identify and Report Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to identify and report an allegation of verbal abuse between two residents to the California Department of Public Health (CDPH) as required by federal regulations and the facility’s own abuse policy. Resident 1 had an intact Brief Interview for Mental Status (BIMS) score of 13 and an active order indicating she was capable of making her own health decisions. Over several weeks, Resident 1 reported that her roommate, Resident 2, kept the television too loud and cursed at her daily. Resident 1 stated staff told her there was nothing they could do, that they could not force Resident 2 to move, and that Resident 1 could move if she did not get along with her roommate, despite Resident 1 having lived in the room for years without prior issues. Resident 1 reported feeling less than a person because staff would not move the roommate who was cursing at her and making her uncomfortable. On one occasion, Resident 1 reported to Licensed Nurse (LN 1) that Resident 2 called her a derogatory slur (“f . c .”) the previous night. LN 1 documented this in the nurse’s notes and acknowledged in interview that the words used were inappropriate and that such behavior could be considered verbal abuse. The Social Services Director (SSD) stated she had been informed at a care conference by Resident 1’s family member that the two residents were not getting along and later learned from LN 1 that Resident 2 had used curse words toward Resident 1. The family member filed a written grievance describing that Resident 2, upset about her TV not working, asked Resident 1 for the remote, was refused, and then called Resident 1 the same derogatory slur. The SSD stated that both residents were capable of making their own medical decisions and that neither had a condition causing uncontrollable speech, but she did not report the incident as abuse because she did not believe it constituted abuse. The MDS nurse stated she became aware of the incident around midday and believed the cursing constituted abuse, and she had LN 1 notify management via the facility’s charting system so the administrator could see it. The Administrator (ADM), identified as the abuse coordinator, stated he was notified of the incident but did not consider it an allegation of verbal abuse because he believed Resident 2 did not have intent. During review of the facility’s Abuse Prevention Policy, the policy defined verbal abuse as willful use of disparaging and derogatory language toward residents or their families, regardless of age or ability to comprehend, and required immediate separation of residents in patient-to-patient abuse and reporting of allegations to CDPH not later than two hours after the allegation is made. The ADM was unable to identify any reference to “intent” in the policy and acknowledged it was the facility’s policy to protect residents from verbal abuse, but he maintained that the incident was not abuse and therefore it was not reported to CDPH as required.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and mental abuse when one resident shoved a walker into another resident's legs, resulting in a skin tear. The incident occurred after an argument between the two residents, one of whom had a diagnosis of dementia and was seated in a wheelchair, while the other was cognitively intact and standing. A certified nursing assistant witnessed the event, confirming that the walker was pushed into the standing resident, causing a skin tear to the left knee with bleeding that required dressing changes. Documentation and interviews confirmed the injury, with the affected resident displaying a circular scab and bruising on the left knee during observation. The facility's abuse prevention policy states that residents must not be subjected to abuse by anyone, including other residents. The incident was recognized by staff as physical abuse, and the injury was directly linked to the altercation between the two residents.
Unsanitary Kitchen Conditions and Expired Food Items
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during a survey. In the dry storage area, a used cookie wrapper was found on a shelf next to condiment sauce bottles. Additionally, a thickener container was left open and exposed to air, containing a piece of yellow cereal and a silver foil piece. The Dietary Manager (DM) acknowledged these unsanitary conditions and confirmed that the area was not maintained according to sanitary standards. In the walk-in refrigeration area, expired food items were discovered. A plastic container of diced apples with an expiration date that had passed was found, as well as a container of boiled eggs that were also expired. The DM confirmed the expiration of these items. The facility's policy and procedure on food storage, which requires routine cleaning and proper storage of dry bulk food in containers with tight covers, was not followed. The US FDA 2022 Food Code also mandates that equipment and surfaces be clean and free of debris, which was not adhered to in this instance.
Inaccessible Call Lights Pose Safety Risk
Penalty
Summary
The facility failed to ensure that call lights were accessible and in good repair for three residents, which posed a safety risk by limiting their ability to call for help. Resident 16, who was moderately cognitively impaired and required substantial assistance for daily activities, had a call light that was not within reach and lacked a red button to press for help. This issue was observed multiple times over several days, and staff confirmed the call light's inaccessibility and the absence of a button. Resident 24, who was severely cognitively impaired and dependent on staff for assistance, also had a call light that was out of reach and missing a red button. Observations confirmed the call light's inaccessibility, and staff acknowledged the safety risk. Despite the facility's process for reporting equipment repairs, there was no record of the missing button being reported for Resident 24. Resident 1, who was severely cognitively impaired and required maximum assistance, had a call light that was out of reach and obscured by other items. Staff confirmed the call light's inaccessibility and the potential harm if the resident attempted to get out of bed without assistance. The facility's policy required call lights to be accessible and defective ones to be reported promptly, but this was not adhered to, as evidenced by the lack of maintenance reports for the missing buttons.
Failure to Notify Responsible Party of Resident Transfer
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's transfer to an acute care hospital, which is a requirement under the facility's policy. The resident, who was admitted in December 2024, had several diagnoses including memory deficit following cerebral vascular disease and dementia, indicating severely impaired cognition. On December 13, 2024, the resident was sent to the emergency room due to disturbing behaviors. However, there was no documentation that the RP was informed of this transfer. During an interview, the Director of Nursing confirmed the lack of notification and stated that the expectation was for the licensed nurse to notify the RP before a resident is transferred. The facility's policy, dated October 2022, requires that appropriate notice be documented in the medical records when a resident is transferred or discharged.
Delayed Submission of MDS for a Resident
Penalty
Summary
The facility failed to submit a Minimum Data Set (MDS) for a resident within the required regulatory timeframe. The resident was admitted and later discharged from the facility, but the discharge assessment was not completed and transmitted within 14 days of discharge as required. During an interview and record review, the MDS Coordinator confirmed that the discharge assessment was delayed. The Director of Nursing expected the MDS Coordinator to adhere to the submission timeframes. The facility's policy and a document titled 'Assessments for the RAI' both stipulated that the MDS completion date for discharge assessments must be completed no later than 14 calendar days after discharge.
Failure to Complete PASARR for Resident with Major Depressive Disorder
Penalty
Summary
The facility failed to ensure that a PASARR (Pre-admission Screening and Resident Review) was completed for one of the sampled residents, who was admitted with a diagnosis of Major Depressive Disorder. The resident was admitted in December 2024, and the PASARR document indicated that if the individual remained in the nursing facility for more than 30 days, a new Level 1 Screening should be resubmitted on the 31st day. During a review of the resident's medical record, it was found that this additional PASARR was not completed. The Director of Nursing and the Administrator confirmed during an interview that the PASARR was missed and acknowledged that it should have been done. A request for additional PASARR documentation and the facility's PASARR policy was made, but no documentation was provided.
Medication and Care Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide services according to professional standards of quality for several residents. For Resident 13, a licensed nurse did not follow the physician's order when administering psyllium powder. Instead of giving the prescribed tablespoon mixed in 8 ounces of water, the nurse administered a teaspoon mixed in 5 ounces of water. This deviation from the prescribed dosage was confirmed by the nurse during a review of the resident's order summary report. Resident 83, who receives nutrition and medication through a feeding tube, experienced a medication administration error. The nurse combined multiple medications and administered them simultaneously through the feeding tube, which led to the tube becoming blocked. The Assistant Director of Nursing confirmed that the medications should have been administered separately with water flushes in between to prevent blockage. Resident 115 was given another resident's insulin supply, and the order for compression socks was not followed. The nurse admitted to using the wrong insulin vial due to being in a hurry. Additionally, there was no documentation of Resident 115's refusal to wear compression socks, and the care plan for their use was not initiated until much later. Resident 33's physician order to flush an indwelling Foley catheter was not followed, leading to the presence of thick yellow sediment and cloudy urine in the catheter tubing. The treatment nurse confirmed that the catheter should have been flushed as ordered.
Failure to Implement Wander Guard Order for Resident at Risk of Elopement
Penalty
Summary
The facility failed to adhere to safety measures for a resident diagnosed with vascular dementia, who was at risk for wandering and elopement. The resident, admitted in November 2024, had an active order for a wander guard to be applied to the left arm or wrist and checked every shift. However, during multiple observations on March 4th, 5th, and 6th, 2025, the resident was not wearing the wander guard as ordered. This oversight was confirmed by the Assistant Director of Nursing during a review of the resident's Order Summary Report and Medication Administration Record. The Director of Nursing acknowledged that the resident should have been wearing the wander guard to ensure safety and prevent wandering incidents. The facility's policy on Wandering and Elopements, revised in 2019, mandates the identification of residents at risk for unsafe wandering and the inclusion of strategies and interventions in their care plans to maintain safety. The failure to follow the order for the wander guard increased the resident's risk for elopement.
Failure to Communicate Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations for a resident during a Medication Regimen Review (MRR) were communicated to the physician. The resident, who was admitted with multiple diagnoses including insomnia, had multiple orders for Melatonin to treat insomnia and regulate circadian rhythm. The Consultant Pharmacist identified an irregularity in the resident's medication regimen, noting two PRN orders for Melatonin and recommended that one should be discontinued. Despite the facility's policy requiring the communication of pharmacy recommendations to the physician, there was no documented evidence that the physician was notified of the pharmacy's recommendation to discontinue one of the PRN Melatonin orders. The Director of Nursing confirmed the presence of multiple PRN orders and acknowledged that one should have been discontinued. However, the Medical Records Director could not find documentation that the physician was informed of the pharmacy's recommendations, leading to a deficiency in the facility's medication management process.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 23.08% for a census of 132 residents. Licensed Nurse 1 (LN 1) did not adhere to the physician's order for Resident 13, administering a teaspoon of psyllium powder in 5 ounces of water instead of the prescribed tablespoon in 8 ounces. This discrepancy was confirmed during a review of Resident 13's Order Summary Report. Additionally, Resident 115, who has Diabetes Mellitus, was administered another resident's insulin glargine due to LN 2's failure to properly check the label on the insulin vial. LN 2 admitted to being in a hurry and not verifying the medication before administration. Furthermore, Resident 83, who receives nutrition and medication through a feeding tube due to anoxic brain damage, experienced a blockage in the feeding tube. LN 2 combined and administered multiple medications simultaneously without flushing the tube between each medication, contrary to the facility's policy. This led to the tube becoming plugged, requiring intervention from the Assistant Director of Nursing. The Director of Nursing confirmed that all nurses had received training in medication administration, including through feeding tubes, and were expected to follow these protocols to prevent such errors.
Medication Error: Insulin Administered from Wrong Supply
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a licensed nurse administered insulin from another resident's supply. Resident 115, who was admitted with Type 1 Diabetes Mellitus, was supposed to receive 22 units of insulin glargine daily in the morning. However, during a medication administration, the nurse did not properly check the label on the insulin vial and used another resident's insulin supply. This error occurred because the nurse was in a hurry and neglected to verify the name on the insulin vial. The incident was observed when the nurse checked Resident 115's blood sugar level, which was 375, and then proceeded to administer the insulin without verifying the correct supply. The Director of Nursing later confirmed that all nurses had undergone skills training in proper medication administration and were expected to follow the seven rights of medication administration. The facility's policy on administering medications, revised in 2019, also emphasized the importance of verifying the right resident, medication, dose, time, and method before administration.
Failure to Update Insulin Label Leads to Potential Medication Error
Penalty
Summary
The facility failed to update the medication label for a resident when their insulin glargine order was changed. The resident, who was admitted with Type 1 Diabetes Mellitus, had an order for insulin glargine to be administered at 22 units daily in the morning. However, during a medication administration observation, it was noted that the label on the insulin vial still indicated a dosage of 27 units, which was incorrect. The Licensed Nurse confirmed the discrepancy between the order and the label on the vial. Further review with the Assistant Director of Nursing confirmed that the insulin vial label had not been updated to reflect the new order of 22 units. The ADON acknowledged that the nurse responsible for changing the order should have updated the label and attached an order sticker to alert other nurses of the change. The facility's policy on administering medications, revised in 2019, requires that medications be administered safely and as prescribed, with the individual administering the medication verifying the correct dose by checking the label.
Lack of Written Agreements for Dialysis Services
Penalty
Summary
The facility failed to ensure that services provided by outside resources had written agreements in place, specifically for dialysis services for two residents. Resident 56 and Resident 96, both diagnosed with end-stage renal disease and dependent on renal dialysis, were receiving dialysis treatments at a clinic without a formal contract between the facility and the dialysis provider. This lack of agreement was confirmed during interviews with the facility's Administrator, who acknowledged that the contract was not available for review. The facility's policies and procedures require written agreements with agencies providing services to residents, including dialysis services. These agreements are meant to outline how care will be managed and how information will be exchanged between the facility and the service provider. Despite these requirements, the facility did not have the necessary agreements in place, potentially leading to a lack of responsibility and accountability in the dialysis services received by the residents.
Infection Control Deficiencies in PPE Disposal, Insulin Administration, and Equipment Maintenance
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. For Resident 15, personal protective equipment (PPE) was not properly contained, with a used gown protruding from a trash bag tied to the closet handle. This was confirmed by a licensed nurse who acknowledged the lack of appropriate disposal containers due to a high number of residents on Enhanced Barrier Precautions (EBP). The infection preventionist also confirmed that improper containment of used gowns poses an infection control issue. For Resident 115, a licensed nurse failed to follow proper infection control practices during insulin administration. The nurse did not disinfect the top of the insulin vial before withdrawing the medication, which was acknowledged as an oversight. The facility's policy requires the disinfection of the vial top to prevent infection, a practice that was not adhered to during the observed medication administration. Resident 46's nebulizer tubing was not changed as scheduled, and the incentive spirometer was improperly stored. The nebulizer tubing was overdue for replacement, and the incentive spirometer was found below the bed, out of the resident's reach. The Director of Nursing confirmed that the nebulizer tubing should be changed every 14 days and stored properly, while the incentive spirometer should be accessible and replaced every 30 days. These lapses in infection control practices increased the risk of infection transmission among residents.
Failure to Maintain Homelike Environment Due to Unrepaired Patio Door
Penalty
Summary
The facility failed to maintain a homelike environment for a resident when a patio door in the resident's room was found to be in disrepair. The resident, who was admitted with multiple diagnoses including muscle weakness, difficulty walking, and depression, expressed discomfort due to the shattered glass patio door covered with plastic. Despite the resident's requests for repair over several weeks, the issue remained unresolved, impacting the resident's comfort and potentially their psychosocial well-being. The maintenance log indicated that the issue was reported on January 4, 2025, but the maintenance director confirmed that only a plastic film was applied and the door was not replaced. An invoice for window repair dated January 27, 2025, was found, but there was no signature of acceptance for the proposed estimate. The facility's policy and procedure for maintenance service, which requires maintaining the building in good repair and free from hazards, was not adhered to in this instance. The administrator was unable to provide documentation of a signed order for the window repair.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident of an injury of unknown origin in a timely manner for a resident with severe cognitive impairment and multiple fractures. The resident was admitted with a pathological fracture of the right humerus and a displaced oblique fracture of the shaft of the humerus, along with dementia. On June 19, a CNA reported the resident's right arm pain, but no swelling was noted. By June 22, the resident's arm was swollen and dark purple, prompting a family member to request an X-ray, which revealed an acute transverse distal humerus supracondylar fracture. The facility's Director of Nursing and Administrator were not informed of the fracture until June 24, despite the X-ray results being available on June 22. The facility's policy requires immediate reporting of suspected abuse or injuries of unknown origin to management and relevant authorities, which was not adhered to in this case. The delay in reporting resulted in a delay in the investigation process and decreased the facility's potential to protect the resident from harm.
Inaccurate MDS Documentation of Resident's Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) for a resident accurately reflected her behavioral symptoms. The resident, who was admitted with severe cognitive impairment and multiple fractures, had a care plan indicating non-compliance with care and aggressive behaviors. However, the MDS Section E did not document these behaviors, despite evidence from the Medication Administration Record (MAR) and staff interviews indicating frequent episodes of physical aggression and combative behavior. Interviews with the Director of Nursing, Restorative Nursing Assistant, and Certified Nursing Assistants confirmed the resident's aggressive behaviors, which were not reflected in the MDS. The MDS Coordinator acknowledged the improper coding of the MDS, which failed to capture the resident's behavioral symptoms. This discrepancy between the MDS and the care plan could lead to inadequate treatment of the resident's behaviors, as the MDS is used to complete the plan of care.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents, Resident 1 and Resident 2, were free from physical abuse when they were involved in a physical altercation. Resident 1, who has moderate cognitive impairment, sustained a skin tear on her right forearm and discoloration on her right upper arm. The incident occurred when Resident 1 attempted to open the balcony door, and Resident 2, who is cognitively intact, wanted to close it. This led to both residents swinging their arms at each other, resulting in Resident 1's injuries. The altercation was confirmed by both residents and documented in their medical records and grievance investigations. Resident 1's medical records indicated that she had a skin tear approximately 3 inches long and bruising on her right upper arm. The Nurse Practitioner noted that Resident 1 reported being hit with a hard object by her roommate, leading to the injuries. Resident 2 confirmed that Resident 1 was swinging her arms and hitting her, which led Resident 2 to push Resident 1. The facility's policy on abuse prevention states that residents have the right to be free from abuse, neglect, and exploitation, but this policy was not upheld in this instance, resulting in physical harm to Resident 1.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report immediately to officials an alleged violation involving physical abuse between two residents. Resident 1 reported on 5/1/24 around 8 p.m. that her roommate, Resident 2, struck the front of her right arm causing a skin tear and discoloration, as well as discoloration on her right upper arm. Both residents confirmed a physical altercation had occurred. However, the facility did not report the incident to the Department within the required two-hour timeframe as per their policy. The licensed nurse and certified nursing assistant were aware of the incident on 5/1/24 but did not notify the Administrator on the same day. During an interview and record review on 5/15/24, the Administrator confirmed that the alleged abuse happened on 5/1/24 and acknowledged that there was no proof the alleged abuse had been reported to the Department within two hours of becoming aware of the situation. The facility's policy, dated 12/2023, stipulates that any suspicion of resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately to the administrator and other officials according to state law. The policy defines 'immediately' as within two hours of an allegation involving abuse or resulting in serious bodily injury.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment for its residents. One resident, admitted with diagnoses including difficulty in walking and low back pain, had a low air loss (LAL) mattress that was not in good working condition. The mattress had two rows of deflated support surfaces in the middle portion, which was confirmed by the Maintenance Supervisor (MS) and Central Supply (CS). Despite the resident's complaints and a Certified Nursing Assistant (CNA) being aware of the issue, no report was made in the maintenance log, and the problem persisted for five months. The Director of Nursing (DON) stated that the expectation was for CNAs to report such issues to either the nurse or maintenance and document it in the maintenance log, which did not happen in this case. Additionally, five of the twelve sampled rooms had holes and peeling paint on the walls. Observations confirmed that rooms 458, 459, 561, 565, and 566 had patches of paint peeling and damage to the drywall. Both the Assistant Director of Nursing (ADON) and the Administrator (ADM) confirmed the disrepair in these rooms. The facility's policy indicated that maintenance service should be provided to all areas of the building and that the building should be maintained in good repair, which was not adhered to in these instances.
Failure to Provide Bladder Retraining Program
Penalty
Summary
The facility failed to administer appropriate treatment and services to maintain continence for a resident who was assessed as a candidate for bladder retraining. Despite being identified as a good candidate for bladder retraining upon admission, the resident did not receive any bladder retraining or scheduled toileting program. This lack of intervention led to the resident's decline in continence, as documented in subsequent assessments and interviews with staff and the resident herself. The resident, admitted with multiple diagnoses including muscle weakness and difficulty in walking, was initially continent and aware of the need to toilet. However, over time, the resident became frequently incontinent. The resident expressed that she could maintain continence if assisted promptly but often had to wait for staff assistance, leading to episodes of incontinence. Staff interviews confirmed that the resident was not placed on any bladder retraining program or scheduled toileting. The facility's policy on urinary continence and incontinence management was not followed, as there was no documented evidence of a toileting plan or bladder retraining being implemented for the resident. The Director of Nursing acknowledged the oversight and confirmed that the resident should have been provided with a toileting retraining program, which was not done, resulting in the resident's decline in bladder function.
Failure to Implement Pharmaceutical Policies and Administer IV Antibiotics
Penalty
Summary
The facility failed to implement its pharmaceutical policies and procedures, affecting a census of 120 residents. During an inspection of the medication room, two used and unsealed E-Kit boxes were found. E-Kit #3 was previously opened with one out of three medications missing, and E-Kit #16 was accessed with one out of four medications missing but not replaced by the pharmacy. The Infection Preventionist (IP) nurse and the Director of Nursing (DON) acknowledged the issue, and the facility's policy indicated that opened kits should be replaced within 72 hours, which was not followed in this case. Additionally, Resident 433's intravenous (IV) antibiotics were not administered per the physician's order. The resident, admitted with sepsis, had an IV antibiotic bag labeled Ampicillin 2 GM/100 ml NS hanging on the IV pole with approximately 30 ml of medication remaining and not attached to the resident. The IP nurse confirmed that the medication was started but not fully administered, and the Assistant Director of Nursing (ADON) verified that the entire medication was not given. The DON stated that staff should follow the doctor's orders and ensure all medication is infused, as per the facility's policy on administering medications.
Unnecessary Administration of Seroquel
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs when the resident was administered Seroquel without adequate indication. The resident, who was admitted with dementia without behavioral, psychotic, or mood disturbances, was prescribed Seroquel for dementia manifested by physical aggression. However, the resident's records showed no documented episodes of physical aggression in the months leading up to and following the prescription. Despite this, the resident continued to receive Seroquel for over six months without documented justification or attempts at dose reduction or non-pharmacological interventions. Interviews with staff, including CNAs and the DON, revealed that the resident did not exhibit aggressive behaviors and was not a danger to herself or others. The DON acknowledged that the clinical records did not support the use of Seroquel and that non-drug interventions were not attempted. The facility's policy on psychotropic medication use emphasized the need for clinical indications and non-pharmacological approaches, which were not followed in this case. The Consultant Pharmacist also confirmed that Seroquel was not FDA-approved for dementia treatment and should only be used short-term for aggression or psychosis, neither of which were documented for the resident. The failure to adhere to these guidelines resulted in the resident receiving unnecessary medication, placing her at risk for adverse effects and further decline in health.
Improper Medication Storage
Penalty
Summary
The facility failed to properly store medications for a census of 120 residents. During an observation of the medication storage room for units 2 and 3, two expired ertapenem intravenous medication bags were found in the medication refrigerator. The Licensed Nurse (LN) acknowledged the expired medications and stated they should have been removed. The Director of Nursing (DON) confirmed that storage rooms are to be checked for expired medications every shift, and the expired medications should have been removed. The facility's policy and procedure (P&P) indicated that nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and expired medications should be returned or destroyed as per the dispensing pharmacy's instructions. Additionally, three loose pills were found in the bottom drawer of a medication cart for unit 2, which were acknowledged by LN 2 and the DON. The DON stated that medication carts are expected to be cleaned after each shift to ensure medications are properly accounted for. Furthermore, two prescription blister packs were found displaced and stuck in the back of the medication cart. LN 2 and the DON acknowledged that the blister packs should not have been stuck there, and the medication carts are expected to be cleaned and prepared for the next shift. The facility's P&P indicated that medications should be stored in an orderly manner to prevent mixing medications of several residents.
Failure to Follow Recipes and Measure Ingredients in Food Preparation
Penalty
Summary
The facility failed to prepare foods that conserved nutritive value, flavor, and palatability when vegetables and pureed meals were prepared without following the recipe with measured ingredients. During an observation in the kitchen, Cook 1 (CK 1) was seen preparing stir fry vegetables and adding unmeasured garlic powder and salt by pouring into her gloved hand. The Registered Dietitian (RD) confirmed that recipes should be followed and ingredients measured to ensure proper taste and nutrition. The facility's recipe for stir fry vegetables specified exact measurements for ingredients, which were not followed by CK 1. Further observations revealed that CK 1 prepared pureed chicken, vegetables, and noodles without measuring ingredients or following recipes. CK 1 added unmeasured amounts of broth and thickener to the blender, resulting in inconsistent preparation. The RD stated that not following recipes for pureed diets could alter nutrition. The facility's policy and procedure on food preparation emphasized the importance of conserving nutritive value, flavor, and appearance by following specific recipes, which CK 1 did not adhere to during the preparation of meals.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety, affecting 117 residents. Observations revealed multiple issues, including improper food labeling, expired foods not being discarded, and food items not being kept at safe temperatures. Specifically, undated cereal bowls, incorrectly dated mayonnaise containers, and expired produce and condiments were found. The egg and tuna salads were stored at temperatures above the safe range, posing a potential health hazard. The Assistant Dietary Manager (AD) and Dietary Manager (DM) confirmed these observations and acknowledged the potential risks involved. Further inspection of the kitchen revealed significant maintenance and cleanliness issues. Ice build-up was observed around the freezer door frame, and ice crystals and freezer burns were found on food items stored in the reach-in freezer. The can opener had missing metal from the cutting blade, and various kitchen areas, including dry food storage and the refrigerator, were found to be dirty with dust, dirt, and food debris. Additionally, a box of lentils was left open to air, and wet pans and a stained blender container were improperly stored. These conditions were confirmed by the AD and DM, who acknowledged the need for maintenance and cleaning. Improper use of a thermometer during food temperature checks was also noted. A cook was observed inserting the full length of the thermometer probe into cooked chicken, with the thermometer head touching the food. The DM confirmed that this was not the correct procedure and that it posed a potential contamination risk. The facility's policies and procedures were reviewed, and it was found that they were not being followed correctly, leading to these deficiencies in food safety and sanitation practices.
Failure to Provide Physical Therapy Services
Penalty
Summary
The facility failed to provide rehabilitation services for Resident 4, who did not receive a physical therapy (PT) evaluation and treatment as ordered by the resident's physician. Resident 4 was admitted with multiple diagnoses, including high blood pressure and heart disease, and had a history of multiple falls, with the last fall resulting in a right femur fracture. Despite a physician's order dated 1/16/24 to start PT and progress to weight-bearing as tolerated, there was no documented evidence that Resident 4 received the required PT evaluation and treatment. Additionally, another physician order dated 3/19/24 to start PT was also not followed, and the resident's physician was not notified of the failure to implement the orders. During an interview, Resident 4 expressed concerns about not receiving therapy and stated that she had been waiting for therapy since January. The Restorative Nursing Assistant (RNA) confirmed that no exercises had been provided to Resident 4 since her leg fracture and that she had informed the rehabilitation director about the resident's desire to walk. The Physical Therapist (PT) acknowledged that Resident 4 had not received PT following her fracture and was unaware of the physician's order dated 3/18/24 due to a lack of communication and the order not being entered into the electronic charting system. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged that the physician orders for PT were not followed and that Resident 4 did not receive the prescribed therapy. The facility's policy on scheduling therapy services indicated that therapy should be scheduled in accordance with the resident's treatment plan and documented in the resident's medical records, which was not adhered to in this case.
Infection Control and Laundry Room Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed in two instances. First, during a medication pass observation, a Licensed Nurse (LN) used a blood pressure monitor to measure a resident's blood pressure and then parked the device in the hallway without cleaning and disinfecting it according to the manufacturer's instructions. The LN admitted to forgetting to clean the equipment between patients. The facility's policy and procedure, as well as the manufacturer's instructions, clearly state that such equipment must be disinfected between uses to prevent infection spread. Interviews with the Infection Prevention (IP) nurse and the Director of Nursing (DON) confirmed that the equipment should have been sanitized before and after use. Second, during an observation of the laundry room, an exhaust fan located above the clean linen area was found to be coated with a thick, sticky substance. The Laundry and Housekeeping Supervisor (LHS) confirmed that the fan had not been cleaned for a while and acknowledged that the substance could contaminate the clean linen when the fan was turned on. The Administrator (ADM) was aware of the issue but indicated that no one had been assigned to clean the fan. The facility's policy on laundry and linen handling emphasizes the importance of maintaining a clean environment to prevent contamination, but this policy was not followed in this instance.
Failure to Complete and Transmit Discharge MDS Assessment on Time
Penalty
Summary
The facility failed to ensure the discharge MDS (Minimum Data Set) assessment was completed and transmitted to the CMS (Centers for Medicare and Medicaid Services) System within the required time frame for one resident, who was part of a census of 120. Resident 112, who had multiple diagnoses including essential hypertension, was discharged from the facility on December 6, 2023. During an interview and record review on April 12, 2024, the MDS Coordinator confirmed that the discharge assessment for Resident 112 was missed and not completed on time. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the discharge assessment should have been completed within 14 days of discharge and transmitted within 7 days after completion. This failure resulted in the most recent MDS resident assessment not being reported to CMS as required.
Inaccurate MDS Documentation of POLST
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for one resident accurately reflected the resident's Physician's Order for Life Sustaining Treatment (POLST). Specifically, the MDS Section S for the resident was inaccurately documented as indicating 'Attempt resuscitation / CPR' when the resident's POLST indicated 'Do Not Attempt Resuscitation (DNR)'. This discrepancy was identified during a review of the resident's clinical record and confirmed by the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON). The MDSC acknowledged that the information should have been corrected during the MDS admission assessment. The resident involved had multiple diagnoses, including acute paralytic syndrome following a cerebral infarction. The inaccurate documentation in the MDS Section S occurred on multiple dates and was not aligned with the resident's expressed wishes as documented in the POLST. The DON confirmed that the MDS assessment should match the POLST to ensure the resident receives appropriate care. This failure had the potential to result in the resident receiving interventions contrary to their choices.
Failure to Refer Resident for PASRR Assessment After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer one of its residents, who had received a new mental illness diagnosis, for a Pre-Admission Screening and Resident Review (PASRR) as required by federal regulations. Resident 22, who had been admitted to the facility in late 2011, was diagnosed with Schizoaffective disorder in November 2021 and Major Depressive disorder in August 2017. Despite these diagnoses, the resident's PASRR Level I assessment, conducted in October 2011, indicated that no referral for a PASRR Level II assessment was needed, and no subsequent referral was made following the new diagnoses. Interviews with the Medical Records Director (MRD) and the Minimum Data Set Coordinator (MDSC) confirmed that Resident 22 was not referred for a PASRR Level II assessment after the new mental illness diagnosis. The Director of Nursing (DON) acknowledged that PASRR assessments should be updated if there is a change in the resident's condition. The facility's policy, effective January 2016, mandates the use of CMS guidelines to ensure that residents with mental illness receive necessary services, but this policy was not followed in the case of Resident 22.
Failure to Develop Comprehensive Care Plan for Resident Refusing Nail Care
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident who was refusing nail care. Resident 20, who was admitted with hemiplegia and hemiparesis following cerebrovascular disease, was observed with extremely long fingernails on the left hand and dirty fingernails on the right hand. Despite being cognitively intact, as indicated by a BIMS score of 14, Resident 20 had been refusing nail care and showers. This refusal was reported by CNA 7 to the nursing staff, but no care plan was developed to address these refusals. During an interview, the DON confirmed that Resident 20's left hand fingernails were extremely long and curling, while the right hand fingernails were dirty, possibly from bowel movement. The DON acknowledged that Resident 20 did not want his nails to be touched and that staff had informed her of his refusals. However, there was no documentation or care plan in place to address this issue, which was against the facility's policy that requires care plans to include measurable objectives and timeframes, and to document any refusals of care by residents.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received necessary nail care. Resident 20, who was admitted with hemiplegia and hemiparesis affecting the right side, was observed with extremely long fingernails on the left hand and dirty fingernails on the right hand. Despite being cognitively intact and dependent on staff for personal hygiene, the resident's nails were not trimmed or cleaned, posing a risk of infection and self-inflicted injury. The resident had been refusing care, including showers, and this refusal was reported to the nurse by the Certified Nursing Assistant (CNA). However, there was no care plan addressing the resident's refusals for nail care, and the staff did not document the risks associated with the refusal or take appropriate interventions as per the facility's policy. The Director of Nursing (DON) confirmed the observations and acknowledged that the resident's refusal to have his nails trimmed was not documented or care planned. The facility's policies on nail care and activities of daily living require staff to document refusals and notify supervisors, but these steps were not followed. The DON stated that her expectation was for staff to document and care plan any new problem or situation, which was not done in this case. The lack of documentation and care planning for the resident's refusal to receive nail care led to the deficiency identified in the report.
Failure to Ensure Adequate Supervision and Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices for two residents, leading to falls. Resident 87, who had a history of falls and required assistance from two staff members, fell while being assisted by a CNA. The CNA turned her back to open a bathroom door, causing the resident to fall backward. The Director of Nursing confirmed that the resident typically required two-person assistance and that the fall could have been prevented with proper supervision. Resident 90, who was in a vegetative state and required two staff members for bed mobility, fell from his bed due to the absence of side rails and fall mats. Despite physician orders and care plan interventions requiring side rails and fall mats, these were not in place at the time of the fall. The Director of Nursing and other staff confirmed the resident's condition and the lack of required safety measures. The facility's policies on resident safety and supervision were not followed, leading to these incidents. The policies required frequent visual checks, proper positioning, and the use of assistive devices like side rails and fall mats, which were not consistently implemented. The deficiencies highlight a failure to adhere to established safety protocols, resulting in preventable falls for both residents.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to provide sufficient fluids to Resident 97, who was identified at risk for dehydration. Despite the Registered Dietitian's assessment indicating a daily fluid need of 1625 ml, Resident 97's average daily intake was only 874 ml, significantly below the required amount. Observations revealed that the resident's water pitcher was consistently placed out of reach, and the resident, who was dependent on staff for feeding and drinking, was not assisted adequately. Interviews with staff confirmed that the resident was unable to drink independently and relied entirely on staff for hydration, yet there was no documented evidence that water was offered at night or that fluid intake was monitored and addressed appropriately in nursing summaries. Resident 97, who had severe cognitive impairment and multiple diagnoses including dementia, was observed multiple times with dry lips and an open mouth, indicating potential dehydration. The Director of Nursing acknowledged that the resident's fluid intake was not meeting the estimated needs and that there was a lack of documentation and monitoring regarding the resident's hydration status. The failure to provide adequate fluids and monitor the resident's hydration placed Resident 97 at further risk for dehydration.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with the physician's order and the resident's care plan for one of the sampled residents, resulting in the resident receiving more oxygen than prescribed. Resident 80, who was admitted in 2021 with multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure, had a physician's order for oxygen at 2 liters per minute (L/min) via nasal cannula. However, during observations on two separate occasions, the oxygen concentrator was set at 3 L/min, exceeding the prescribed amount. Licensed Nurse 5, who was familiar with Resident 80's care, confirmed that the oxygen was being delivered at 3 L/min instead of the ordered 2 L/min and acknowledged that the oxygen delivery should be checked every shift. The facility's policy on oxygen administration, dated October 2010, requires reviewing the physician's orders and the resident's care plan to ensure the proper flow of oxygen is administered. The Director of Nursing (DON) validated that administering supplemental oxygen at a higher rate could be harmful to Resident 80's health and emphasized that nurses are expected to follow the physician's orders. This failure to adhere to the prescribed oxygen therapy had the potential to cause serious health complications for Resident 80.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when one of the four covers of the garbage dumpster was found open during an observation and interview with the Assistant Dietary Manager (AD) in the parking lot. The AD confirmed the observation and acknowledged that the dumpster should have been shut to prevent bacteria contamination. The facility's policy and procedure (P&P) indicated that garbage and trashcans must be inspected daily to ensure no debris is on the ground or surrounding area and that the lids are closed. Additionally, the US FDA 2022 Food Code requires outside receptacles for refuse containing food residue to have tight-fitting lids, doors, or covers. This deficiency was observed during a kitchen tour for a facility with a census of 120 residents, highlighting a failure to adhere to proper waste disposal protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 539 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woodland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottonwood Healthcare Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Woodland Post-acute | 0.8 mi | ★★★★★ | 25 | 0 |
| University Retirement Community At Davis | 8.3 mi | ★★★★★ | 23 | 0 |
| Courtyard Health Care Center | 9.2 mi | ★★★★★ | 7 | 0 |
| River Bend Nursing Center | 14.8 mi | ★★★★★ | 31 | 0 |
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