Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Springs Health And Rehabilitation Center during CMS and state inspections, most recent first.
Food storage, sanitation, and hand hygiene lapses were observed in the kitchen and clean utility room areas. Surveyors found undated ham and cheese sandwiches, undated meat in the freezer, and unlabeled, undated food items in a refrigerator, along with ketchup stored with the lid open to air and residue on a piece of the ice machine. During tray line prep, a large can of tomato sauce was placed on a tray for garlic bread, and a DA returned to food prep without washing hands after leaving the kitchen.
A resident with HTN and CKD did not receive PRN hydralazine when SBP was above the ordered threshold on multiple occasions, and staff, the ADON, and the DON acknowledged the medication should have been given. Another resident with DM and ESRD had long-acting insulin therapy but lacked routine BG monitoring for extended periods despite repeated hyperglycemia and elevated HgbA1c results, and staff stated there was no routine BG order during that time.
Staff failed to follow EBP and infection control practices for multiple residents. A TN provided wound care to a resident with a pressure ulcer and EBP orders without a gown, a CNA transported a soiled linen bag without gloves and with the bag touching clothing, and a PTA and COTA transferred a resident with EBP orders for enteral feeding and a PICC line without gowns during a high-contact transfer. EBP signage was posted, but PPE gowns were not stocked in or outside the rooms.
A resident with dementia, psychosis, and depression received PRN lorazepam for anxiety manifested by SOB, but the MAR and progress notes showed eight administrations without documented monitoring of the target behavior. The DON, ADONs, and record review confirmed there was no physician order for target-behavior monitoring, despite the facility’s expectation that nursing staff document the resident’s response during use of the psychotropic medication.
IV Medication Emergency Kit Not Replaced Within Required Timeframe: An IV Medication E-kit was found opened and still in use beyond the facility’s 72-hour replacement timeframe. The ADON could not locate the medication slips or identify when the kit was opened, and record review showed that Ertapenem and Vancomycin vials had been removed from the kit on separate occasions. The DON stated nursing staff were expected to call the pharmacy immediately after an E-kit was opened and the pharmacy was expected to replace it within 72 hours.
Failure to Act on CP Recommendations: Two residents had pharmacist recommendations that were not documented as referred to the MD for action. One resident received heparin for DVT prophylaxis without a documented duration of therapy, and the CP asked for clarification. Another resident with DM and ESRD had repeated blood glucose readings above 300 mg/dl while on insulin, and the CP requested MD evaluation, but the chart did not show physician evaluation of the elevated readings.
A resident receiving heparin for DVT prophylaxis after a lumbar compression fracture was found to have improved mobility, including ambulation with a FWW and the ability to propel a wheelchair inside the facility. Record review showed no documented evaluation of the continued need for the anticoagulant, and the ADON acknowledged the lack of documentation that the physician reviewed ongoing use despite the resident's current mobility status.
The facility did not provide required notice of transfer or discharge to the State LTC Ombudsman prior to the planned discharge of three residents with complex medical needs, despite facility policy and federal requirements. Staff interviews confirmed the omission, and there was no documentation in the records that the Ombudsman was notified before the discharges.
A resident admitted for hospice care with dementia and Parkinson's disease was prescribed lorazepam and quetiapine for anxiety and psychosis, but staff did not initiate monitoring for targeted behaviors or medication side effects until two days after starting the medications. Nursing staff and leadership confirmed that monitoring should have begun with the initiation of psychotropic medications, as required by facility policy.
A resident with a history of heart failure and kidney disease was transferred to a hospital due to low blood pressure and oxygen levels, but the facility failed to notify the responsible person and emergency contacts. The resident was admitted to the ICU and passed away shortly after. The facility's DON acknowledged the communication lapse, as the charge nurse assumed others had notified the family, contrary to the facility's policy.
A resident with acute congestive heart failure and other conditions was transferred to a GACH due to low blood pressure and oxygen levels. The facility failed to notify the resident's family of the transfer, resulting in the family discovering the resident's absence the following day. The resident was admitted to the ICU and passed away shortly after. The DON acknowledged the communication lapse, as the LVN responsible assumed others had notified the family.
A resident with atherosclerotic heart disease and polyneuropathy did not receive pain medications as ordered, leading to unmanaged pain. The MAR showed morphine sulfate was given for moderate pain and tramadol for mild and severe pain, contrary to physician orders. The DON confirmed the discrepancy, and the facility's policy emphasized proper medication administration and pain assessment.
A resident with a known allergy to aspirin was administered the medication for 19 days due to a failure to update the allergy list, resulting in a severe allergic reaction and hospitalization. Despite the resident's history, the facility did not prescribe medication to treat the allergic reaction symptoms, leading to a life-threatening condition.
The facility failed to ensure accurate MDS assessments for two residents, one with unplanned weight loss inaccurately coded as a physician-prescribed regimen, and another with severe cognitive impairment whose use of bed and wander alarms was not reflected in the MDS. Interviews confirmed the discrepancies between documented care and MDS coding.
A facility failed to ensure staff donned PPE before entering the room of a resident on contact precautions for MRSA. Despite a policy requiring gloves and gowns, a CNA entered the room without PPE. The resident was admitted with right foot osteomyelitis and was under contact isolation. Interviews confirmed staff awareness of the precautions, yet the protocol was not followed.
A resident with severe cognitive impairment and other mental health conditions was verbally abused by a CNA, who used explicit language towards the resident in the hallway. Multiple staff members confirmed the incident, and the CNA was terminated following an investigation.
The facility failed to report an incident of verbal abuse towards a resident to the CDPH within the required two-hour timeframe. Multiple staff members overheard the abuse, but the incident was not reported to the DSD until several hours later, resulting in a delay in notifying the CDPH. The resident involved has severe cognitive impairment and was exhibiting increased confusion and agitation at the time.
A facility failed to remove a CNA from patient care after the CNA was witnessed verbally abusing a resident with severe cognitive impairment. Despite immediate knowledge of the abuse, the CNA remained in the facility for approximately two hours, violating the facility's abuse prevention policy.
Food Storage, Sanitation, and Hand Hygiene Lapses in Kitchen Areas
Penalty
Summary
The facility failed to ensure food safety and sanitation were maintained in the kitchen and related storage areas. During an initial kitchen inspection with the Dietary Manager, surveyors found multiple ham and cheese sandwiches in Refrigerator 1 and in the Station 2 clean utility room refrigerator that were undated, two packages of meat in the freezer that were undated, and multiple food items in the Station 3 clean utility room refrigerator that were both unlabeled and undated. Surveyors also observed a plastic container of ketchup in the kitchen refrigerator with the lid open to air, and a small amount of orange-colored residue on a white rubber piece inside the ice machine in the Station 2 clean utility room. The Dietary Manager stated the sandwiches should have been dated, the ketchup lid should not have been open to air, and the food items should have been dated when prepared. During a later observation of tray line preparation, a large can of tomato sauce was placed on a tray intended for garlic bread on the kitchen counter. In a concurrent interview, the Dietary Manager stated the can should not have been placed on top of the tray. At the same time, a Dietary Aide was observed leaving the kitchen and returning to the food preparation area to assist with desserts without washing hands. The Dietary Manager stated the Dietary Aide should have washed hands after leaving and before returning to food prep. Facility policies reviewed included food storage requirements to label and date food items, use tight-fitting lids on opened products, routine ice machine cleaning, infection prevention and control, and hand washing before starting work in the kitchen and before and after handling food.
Missed PRN antihypertensive doses and inadequate glucose monitoring
Penalty
Summary
Hydralazine was not administered as ordered for a resident with heart failure and hypertensive chronic kidney disease. The physician ordered hydralazine 25 mg by mouth every 12 hours as needed for hypertension when systolic blood pressure was greater than 150 mmHg, along with blood pressure monitoring every 12 hours for hydralazine use. Review of the MAR and blood pressure results showed multiple occasions when the resident’s systolic blood pressure was above 150 mmHg and the medication was not given, including readings in March, April, May, June, August, September, October, November, and December 2025. Nursing staff, the ADON, and the DON acknowledged that hydralazine should have been administered when the blood pressure met the ordered parameter. For the resident with diabetes mellitus and end stage renal disease, blood sugar monitoring was not closely managed in relation to long-acting insulin therapy. The resident had been receiving Lantus, and the record showed repeated episodes of marked hyperglycemia in January 2025, including blood glucose values over 400 mg/dL and one value of 571 mg/dL. The record also showed periods when no blood sugar monitoring was documented for extended portions of the day despite these elevated readings and ongoing insulin use. Staff stated there was no routine order for blood sugar checks from January 2025 until September 2025, even though the resident had multiple high blood sugar readings. The resident’s record further showed that blood sugar checks were being done at least three times a week before dialysis appointments, but there was no documented evidence that the resident’s elevated HgbA1c results, including 8.0 and 8.7, were addressed with evaluation of insulin therapy and blood sugar monitoring frequency. The care plan identified the resident as at risk for hypo/hyperglycemia related to diabetes and long-term insulin therapy, and the facility’s diabetes protocol stated that monitoring frequency should be adjusted based on glucose control and physician orders. The ADON stated the resident’s long-term insulin therapy should have been evaluated for the need for routine blood sugar monitoring.
Failure to Use PPE for EBP Care and Soiled Linen Handling
Penalty
Summary
The facility failed to implement infection prevention and control measures for residents on Enhanced Barrier Precautions (EBP) and for handling soiled linen. Resident 33 had EBP signage posted outside the room, but no PPE gowns were visible stocked in or outside the room. Resident 33 was cognitively intact, had a stage 3 pressure ulcer to the left buttocks, and had physician orders for EBP related to an indwelling foley catheter and the left gluteal fold wound. During observation and interview, the Treatment Nurse acknowledged that gowns should be worn for wound care, but the nurse was observed providing wound care without PPE gowns available in the room or outside the room. Resident 33 also stated staff wore gloves but did not wear gowns during wound care and catheter care. The facility also failed to follow its infection control practices when a CNA transported a large soiled linen bag from a resident room to the soiled utility room without wearing gloves. The bag was observed touching the CNA's clothing during transport. The Infection Preventionist stated the soiled linen bag should not touch a staff member's body because it had touched the floor and was considered dirty. The DON stated the bag should be kept away from the clothing and body while being transported. The facility policy for soiled laundry and bedding stated that anyone handling soiled laundry wears protective gloves and other appropriate PPE. A similar failure occurred with Resident 200, who had EBP orders for enteral feeding and a RUA PICC line and was cognitively intact. EBP signage was posted outside the room, but no PPE gowns were visible stocked in or outside the room. When Resident 200 returned from rehab and was transferred from wheelchair to bed by a PTA and COTA, both staff members wore gloves but were observed without yellow gowns during the close-contact transfer. During interview, both therapy staff stated that transferring the resident was a high-contact activity and that gowns and gloves should have been worn. The DON stated gowns and gloves were required for significant contact such as transfers, ADLs, wound care, urinary catheter care, IV care, and GT care.
Unmonitored PRN lorazepam use
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary psychotropic medication use when lorazepam was administered without adequate behavioral monitoring. Resident 16 was admitted and later readmitted with diagnoses including dementia, psychosis, and depression. The resident had a physician’s order dated December 8, 2025, for lorazepam oral concentrate 0.5 ml by mouth every 4 hours as needed for anxiety manifested by shortness of breath. Review of the medical record showed there was no physician’s order to monitor the target behavior, anxiety manifested by shortness of breath, during lorazepam use. The resident’s MAR and progress notes from December 8, 2025, through December 11, 2025, showed lorazepam was administered eight times, and there was no documented evidence that the target behavior was monitored and documented by nursing staff at those times. During interviews, the DON, ADON 1, and ADON 2 confirmed there was no order to monitor the target behavior when lorazepam was given, and the DON stated the expectation was for nursing staff to document the target behavior during use of lorazepam.
IV Medication Emergency Kit Not Replaced Within Required Timeframe
Penalty
Summary
The facility failed to ensure that one of two IV Medication Emergency Kits was replaced within 72 hours after being opened, as required by the facility's policy and procedure. During an observation in the medication storage room, one IV Medication E-kit was found sealed with a yellow lock, which the ADON identified as indicating the kit had been opened and needed replacement by the pharmacy. The ADON stated that nursing staff were expected to complete a medication slip, leave copies in the logbook and inside the kit, reseal the kit with a yellow lock, and immediately call the pharmacy to reorder it, with the pharmacy expected to replace it within 72 hours. The ADON was unable to locate the medication slips or identify when the kit had been opened at the time of the observation. The pharmacy label showed the kit had been filled on November 27, 2025, and review of nursing progress notes later identified that one Ertapenem 1 g vial was removed on November 30, 2025, and one Vancomycin 1 g vial was removed on December 3, 2025. The ADON acknowledged the IV Medication E-kits were not replaced within 72 hours according to policy, and the DON stated the expectation was for nursing staff to call the pharmacy immediately after a kit was opened and for the pharmacy to replace it within 72 hours so emergency medications would be available when needed.
Failure to Act on Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure consultant pharmacist recommendations were acted upon for two residents reviewed for unnecessary medications. For one resident, who was admitted with diagnoses including a wedge compression fracture of the lumbar vertebrae and was observed using a wheelchair while also participating in an ambulation program with a front wheel walker, the physician order dated May 7, 2025 included heparin sodium injection 1 ml subcutaneously every 12 hours for DVT prophylaxis. The consultant pharmacist’s medication regimen review dated May 17, 2025 asked for a duration of therapy for heparin, but the record did not show that this recommendation was referred to the physician for action. For another resident, who had diagnoses including diabetes mellitus and end stage renal disease and was cognitively intact with a BIMS score of 15, the record showed repeated elevated blood sugar readings. The resident’s care plan identified risk for hypo/hyperglycemia and included collaboration with the pharmacist and attending physician to adjust insulin and blood sugar check frequency as needed. The physician orders dated September 12, 2025 included Lantus SoloStar insulin, and the resident had 22 blood sugar readings above 300 mg/dl in September and 27 readings above 300 mg/dl in October. The consultant pharmacist’s medication regimen review dated October 22, 2025 stated that the resident’s blood sugar had been greater than 300 on several occasions and asked that the MD be aware to evaluate. The physician progress note dated November 4, 2025 did not indicate evaluation of the elevated blood sugars, and the record did not show that the pharmacist recommendation was referred to the physician for action. The ADON stated there was no documentation that either pharmacist recommendation had been referred for appropriate action.
Unnecessary Heparin Use Not Evaluated
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met for one resident when heparin ordered for DVT prophylaxis was not evaluated for continued use. Resident 7 was admitted with a diagnosis that included a wedge compression fracture of the lumbar vertebrae, and the physician ordered Heparin Sodium Injection 1 ml subcutaneously every 12 hours on May 7, 2025 for DVT prophylaxis related to immobility. The resident was observed sitting in a wheelchair in the dining room and stated he could propel his wheelchair inside the facility. Record review showed Resident 7 had progressed in mobility over time, including ambulation with a two-wheeled walker up to 175 feet in therapy notes, and an MDS dated November 4, 2025 indicated supervision was needed for walking 50 feet with two turns. RNA documentation and interview also showed the resident was on an ambulation program with a front wheel walker five times per week and could ambulate about 150 feet with a steady gait. The record contained no documented evidence that the continued use of heparin for DVT prophylaxis was evaluated, and the ADON stated there was no documentation showing the physician reviewed the ongoing need for heparin despite the resident's improved mobility.
Failure to Notify Ombudsman Prior to Resident Discharge
Penalty
Summary
The facility failed to provide a copy of the notice of transfer or discharge to the State Long-Term Care Ombudsman prior to the planned discharge for three sampled residents. For each resident, documentation showed that the resident and their representative were notified of the discharge, and the discharge was carried out as planned. However, there was no evidence in the records that the Ombudsman was notified prior to the discharge, as required by facility policy and federal regulations. Interviews with facility staff, including the Social Worker, Case Manager, and Assistant Administrator, confirmed that the process for notifying the Ombudsman was not followed, with explanations including uncertainty about the Ombudsman's coverage and issues with email communication. The residents involved had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction, metabolic encephalopathy, dementia, acute osteomyelitis, and dissection of the descending thoracic aorta. Despite the facility's policy requiring notification of the Ombudsman and documentation of such notification in the medical record, this step was omitted for all three residents prior to their discharge. The facility's own policies also require that residents and their representatives be informed of their right to appeal the discharge, including contact information for the Ombudsman, but the lack of Ombudsman notification was a clear deficiency in the discharge process.
Failure to Monitor Behaviors and Side Effects for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring of a resident who was admitted under general in-patient hospice care with diagnoses including dementia, Parkinson's disease, and uncontrolled behaviors posing a danger to self and others. Upon admission, the resident was prescribed psychotropic medications, specifically lorazepam for anxiety, restlessness, agitation, and shortness of breath, and quetiapine fumarate for psychosis and unprovoked physical behavior. However, there was no documented evidence that monitoring for targeted behaviors such as anxiety and psychosis, or for side effects related to the use of these psychotropic medications, was initiated until two days after admission. Interviews with nursing staff and facility leadership confirmed that monitoring for behaviors and side effects should have been conducted from the time the medications were started. The facility's own policy required staff to monitor for adverse side effects associated with psychotropic medication use. The lack of timely monitoring was acknowledged by the RN, ADON, LVN, and DON, all of whom stated that such monitoring was expected and should have been implemented as soon as the medications were ordered.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible person (RP) and emergency contacts of a resident's change of condition and subsequent transfer to a general acute care hospital (GACH). On January 17, 2025, the resident experienced low blood pressure and low oxygen levels, prompting the facility to initiate intravenous fluid hydration and consider an X-ray. The RP was informed of the low blood pressure and potential X-ray but was not updated about the resident's transfer to the hospital. The following day, a family member discovered the resident was not in their room and was informed by staff that the resident had been transferred to the GACH due to low blood pressure and low oxygen levels. The resident, who had a medical history including acute congestive heart failure, atrial fibrillation, and chronic kidney disease, was admitted to the intensive care unit at the GACH and passed away on January 19, 2025. The facility's Director of Nursing (DON) acknowledged the communication lapse, stating that the charge nurse, LVN 1, assumed other nurses had notified the RP, which did not occur. The facility's policy requires notifying the resident's representative of significant changes in health status, which was not adhered to in this case.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to accurately document the notification of the Responsible Person (RP) regarding the transfer of a resident to a general acute care hospital (GACH). On January 17, 2025, the resident was transferred due to low blood pressure and low oxygen levels. However, the RP and family members were not informed of this transfer, leading to a lack of awareness about the resident's critical condition and subsequent admission to the Intensive Care Unit. The RP only discovered the transfer when a family member visited the facility the following day and found the resident missing from their room. The resident, who had been admitted to the facility with acute congestive heart failure, atrial fibrillation, and chronic kidney disease, passed away on January 19, 2025. The facility's documentation indicated that the RP was notified at 6:30 p.m. on the day of the transfer, but interviews and record reviews revealed that this notification did not occur. The Director of Nursing acknowledged the communication lapse, and it was found that the Licensed Vocational Nurse (LVN) responsible for the resident's care assumed that other nurses had informed the RP, which was not the case.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The facility failed to administer pain medications as ordered by the physician for a resident, leading to potential unmanaged pain. The resident, who was admitted with diagnoses including atherosclerotic heart disease and polyneuropathy, had specific orders for pain management. The care plan indicated that medications should be administered as ordered, with tramadol prescribed for moderate pain and morphine sulfate for severe pain. However, the Medication Administration Record (MAR) showed that morphine sulfate was given for moderate pain and tramadol was administered for mild and severe pain, contrary to the physician's orders. The Director of Nursing (DON) confirmed during an interview that the medications were not administered according to the physician's orders. The facility's policy on pain assessment and management emphasized the importance of administering medications as ordered and conducting comprehensive pain assessments. Despite this, the resident's pain was not managed appropriately, as evidenced by the hospice nurse's progress note indicating the resident's pain was not controlled with the current medication regimen. The resident also exhibited signs of distress, such as confusion, sadness, and refusal of wound care.
Failure to Prevent and Treat Allergic Reactions
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and treatment to prevent and treat allergic reactions. The resident, who had a known allergy to aspirin, was administered the medication for a total of 19 days. This oversight occurred because the resident's allergy to aspirin was not listed in the facility's allergy list, despite being documented in previous medical records. The administration of aspirin led to the resident developing a severe allergic reaction, resulting in toxic epidermal necrolysis, a life-threatening condition. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) were aware of the resident's allergies, but the allergy list was not updated to include aspirin. The Medical Doctor (MD) acknowledged that the resident's allergy to aspirin was known, but the medication was continued due to its perceived benefits for the resident's stroke condition. The facility's failure to accurately document and communicate the resident's allergies led to the administration of a contraindicated medication, resulting in severe adverse effects. The resident's family expressed concerns about the administration of medications to which the resident was allergic. Despite the resident's history of allergic reactions, the facility did not prescribe or administer medication to treat the allergic reaction symptoms. The resident's condition worsened, leading to hospitalization for further evaluation and treatment. The facility's policies on monitoring and documenting adverse drug reactions were not adequately followed, contributing to the deficiency in care.
Inaccurate MDS Assessments for Nutrition and Dementia Care
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents, leading to deficiencies in the areas of nutrition and dementia care. For one resident, the MDS inaccurately indicated that their weight loss was due to a physician-prescribed weight-loss regimen, despite the absence of any such order. Interviews with the MDS Coordinator, MDS Assistant, and the Director of Nursing confirmed that the resident's weight loss was unplanned and due to poor intake, and the MDS should have been coded accordingly. For another resident, the MDS did not accurately reflect the use of a bed alarm or a wander/elopement alarm, despite documentation in the resident's care plan and progress notes indicating their use. The resident had severe cognitive impairment and was at risk for falls and wandering, necessitating these interventions. The Director of Nursing acknowledged the need for accurate MDS assessments, highlighting the discrepancy between the documented interventions and the MDS coding.
Failure to Adhere to PPE Protocols for Contact Precautions
Penalty
Summary
The facility failed to ensure that staff properly donned personal protective equipment (PPE) before entering the room of a resident on contact precautions. The facility's policy, revised on September 1, 2023, required staff to wear gloves and gowns when entering the room of residents with infections transmitted by direct or indirect contact, such as MRSA. Despite this policy, a Certified Nursing Assistant (CNA) entered the room of a resident diagnosed with MRSA without wearing any PPE. The resident had been admitted from a hospital with a diagnosis of right foot osteomyelitis and was under contact isolation for a right foot wound. An observation on July 2, 2024, noted a sign on the resident's door indicating the need for contact precautions, including the use of gloves and gowns. During an interview, the CNA acknowledged awareness of the contact precautions but failed to comply. The Director of Nursing and the Administrator both stated that staff were expected to wear the appropriate PPE before entering rooms of residents on contact precautions. This incident highlights a lapse in adherence to established infection control protocols within the facility.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse when a CNA was witnessed using explicit language towards the resident in the hallway. The incident occurred on March 28, 2024, at around 4:30 a.m., when multiple staff members overheard CNA 2 telling the resident, 'Shut the fuck up, you are a grown woman, why are you acting like that?' The facility's Assistant Administrator confirmed that the verbal abuse was substantiated through their investigation, and CNA 2 was terminated as a result. The resident involved had severe cognitive impairment, dementia, anxiety disorder, psychotic disorder, and mood disorder, and was observed to be calm but easily awakened with no physical injuries noted. Interviews with various staff members, including CNA 1, CNA 3, and CNA 4, corroborated the incident. CNA 1 reported hearing the explicit language while attending to another resident, and CNA 3 and CNA 4 also confirmed hearing the verbal abuse from CNA 2. The facility's policy on abuse prevention emphasizes the importance of providing an environment that prohibits and prevents abuse, including the use of derogatory language. Despite these policies, the incident of verbal abuse occurred, highlighting a failure in supervision and staff behavior management.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an incident of verbal abuse towards Resident A to the California Department of Public Health (CDPH) within the required two-hour timeframe. On March 28, 2024, at around 4:30 a.m., CNA 2 verbally abused Resident A by saying, 'Fuck you, you are a grown woman, why are you acting like this?' This incident was overheard by multiple staff members, including CNA 1, CNA 3, and CNA 4. However, the incident was not reported to the Director of Staff Development (DSD) until around 11:30 a.m. by CNA 1, and subsequently, the CDPH was not notified within the mandated two-hour period. The delay in reporting was confirmed during an unannounced visit on April 10, 2024, and through interviews with the Assistant Administrator (AADM) and other staff members involved. Resident A, who has severe cognitive impairment with a BIMS score of 3, was admitted to the facility with diagnoses including dementia, anxiety disorder, psychotic disorder, and mood disorder. The resident's progress notes indicated increased confusion, agitation, and aggressive behavior on the day of the incident. Despite the facility's policy requiring immediate reporting of any alleged abuse, the staff failed to comply, resulting in a delay in the investigation and reporting of the verbal abuse incident. This failure potentially placed Resident A and other residents at risk for further abuse.
Failure to Remove CNA After Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident was free from further abuse when a CNA was not removed from all patient care after being witnessed verbally abusing a resident in the hallway. The incident occurred on March 28, 2024, when CNA 2 was overheard by multiple staff members telling Resident A, 'Fuck you, you are a grown woman, why are you acting like this?' Despite the immediate knowledge of the abuse, CNA 2 was not removed from the facility until approximately two hours later. This delay in action was confirmed by the Assistant Administrator and multiple staff members, including CNA 1, CNA 3, and CNA 4, who all provided consistent accounts of the incident and the failure to follow protocol by LVN 1, who did not remove CNA 2 immediately after the abuse was known. Resident A, who has severe cognitive impairment with a BIMS score of 3, along with diagnoses of dementia, anxiety disorder, psychotic disorder, and mood disorder, was the victim of the verbal abuse. The resident's progress notes indicated increased confusion, agitation, and aggressive behavior on the day of the incident. The facility's policy on Abuse Prohibition and Prevention, which mandates the immediate suspension of personnel involved in abuse allegations, was not followed, leading to a potential risk for further abuse to Resident A and other residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Murrieta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Murrieta Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 21 | 0 |
| Temecula Healthcare Center | 6.4 mi | ★★★★★ | 7 | 0 |
| Menifee Lakes Post Acute | 12 mi | ★★★★★ | 10 | 0 |
| Fallbrook Skilled Nursing | 12.1 mi | ★★★★★ | 2 | 0 |
| Hemet Hills Post Acute | 16.6 mi | ★★★★★ | 7 | 0 |
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