Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at University Park Healthcare Center during CMS and state inspections, most recent first.
Failure to Protect Resident from Physical Abuse by Another Resident: A bedbound resident with limited functional ability was struck on the head with an overhead table by another resident who had documented aggressive and abusive behaviors. The injured resident sustained a scalp laceration, blunt trauma, and a closed head injury, required ED treatment with staples, and later stated he was afraid when the other resident hit him. The aggressor had prior incidents of verbal aggression, threats, and spitting, and the DON stated the resident required supervision to prevent further abuse.
Failure to Report, Investigate, and Prevent Resident-to-Resident Abuse: A resident with schizoaffective disorder and aggressive behaviors threatened and spit on another resident, but staff did not recognize the conduct as abuse, did not report it to the Ombudsman, police, or CDPH, and did not complete the required monitoring documentation. The same resident was later placed in a room with a bedbound resident and allegedly struck that resident with an overhead table, causing a head laceration and hospital transfer. The DON and an LVN stated spitting was not abuse, while the record showed the facility’s policies required abuse identification, investigation, and reporting.
Failure to report and investigate resident-to-resident abuse. A resident with schizoaffective disorder and a history of agitation threatened another resident, called the resident names, and spit on the resident, with the spit landing on the resident’s shirt. The DON and an LVN stated spitting was not abuse and did not report the incident to the Ombudsman, CDPH, or police, even though the facility later acknowledged the event should have been reported and investigated.
A resident with dementia, impaired cognition, weakness, abnormal posture, and a history of falls slid off a WC during a transfer from a car after returning from pass. The transfer was performed by a CNA and the resident’s family member, despite the resident requiring a 2-person assist and the facility policy calling for family training on safe transfers and use of assistive devices. Staff later acknowledged the resident needed 2-person assistance and may not have been properly positioned in the WC.
Controlled medication counts in one med cart did not match the Narcotic and Hypnotic Records for several residents. An LVN said she administered the missing doses of lorazepam, clonazepam, phenobarbital, and hydrocodone/APAP but did not sign the records because she was distracted by other tasks, despite the facility policy requiring the nurse to document the time, quantity remaining, and signature upon administration.
Medication administration errors exceeded the allowed rate, with multiple wrong-medication and wrong-order events observed. An LPN gave a resident senna/docusate instead of ordered senna, gave another resident the wrong senna product and metformin without the ordered meal timing, and gave a third resident the wrong multivitamin formulation and the wrong lidocaine patch strength from another resident’s supply. The facility’s policy required checking the label three times and giving meds as prescribed.
Failure to follow the pureed bread recipe and renal diet menu led to incorrect food service at lunch. A pureed bread item was served lumpy, dry, grainy, and sticky instead of smooth IDDSI Level 4 texture, and two residents on a renal diet were served chicken nuggets and white rice instead of the planned turkey pattie with gravy and wheat pasta. Cook and RD interviews confirmed the menu and standardized recipe were not followed.
Unsafe dry food storage practices were observed in the kitchen when a scoop was left inside a bulk rice bin with the handle touching the food, and bulk oatmeal, rice, and flour were stored in bins lined with regular trash bags instead of food grade bags. The DS stated the scoop could contaminate the food and that the liners were not food grade; facility policy required sanitized bins or food grade bags and that scoops not be left in the containers.
A resident with mood affective disorder, schizoaffective disorder, anxiety, and severely impaired cognition received Haldol 10 mg at bedtime for a broad manifestation of “responding to internal stimuli.” Staff interviews showed the nurses and DON could not clearly define or consistently interpret that behavior, and the order was not specific enough to support accurate monitoring of the resident’s symptoms.
A resident with dysphagia, gastrostomy, and severe cognitive impairment had a TF care plan that still listed Jevity 1.5 at 55 ml/hr even after a new MD order changed the formula to Glucerna 1.2 at 70 ml/hr via g-tube. RN and DON both confirmed the care plan was not revised to reflect the current order and current plan of care.
Incomplete Dialysis Communication Records: A resident with ESRD and dependence on renal dialysis received scheduled HD treatments, but the facility did not complete the Dialysis Communication Record as required. Post-dialysis assessments were missing for some sessions, and several dialysis visits had no record at all. RN and DON both confirmed the omissions, and the facility policy required documentation of catheter/access details, post-dialysis report, and observations for each dialysis session.
Improper Storage of Refrigerated Medications: An unopened insulin lispro pen was found stored at room temperature on one med cart, and a bottle of gabapentin solution was also found at room temperature on another med cart. Product and pharmacy labeling indicated both medications required refrigeration, and an LVN confirmed the storage conditions did not match the labeling.
Failure to Communicate Pre-Appointment Instructions for CT Angiogram: A cognitively intact resident with ESRD and dialysis dependence was scheduled for a CT angiogram and cardiac echo with instructions to fast and receive dialysis after the appointment. The SSD and RN confirmed the resident was not told the fasting and dialysis instructions, so the resident ate and went to dialysis before the appointment, preventing the CT angiogram from being completed and requiring rescheduling.
Call Light Not Within Resident Reach: A resident with dementia, spinal spondyloarthropathy, depression, and a moderate fall risk was unable to reach the call light after staff changed the bed linens. The resident required max assistance with ADLs and stated she depended on the call light for help, but observation showed the cord clipped to the bedsheet at the head of the bed and dangling out of reach. CNA, LVN, RN, and DON interviews confirmed the call light was not within easy reach as required by the care plan and facility policy.
A resident with paranoid schizophrenia and psychosis had a physician order and care plan for Depakote 125 mg BID to manage delusions. Over an extended period, the resident repeatedly refused Depakote at scheduled doses, including multiple consecutive refusals documented on the MAR. Staff reported that medication should be offered twice and the physician notified when refusals occurred, and the facility’s change-in-condition policy required physician notification after two or more consecutive refusals. However, there was no documentation that the physician or psychiatrist was notified of these refusals until a change-of-condition note was entered and the primary physician was contacted much later, despite the DON and RN supervisor acknowledging the importance of the medication for controlling the resident’s delusions.
Physician-ordered daily wound care and monitoring were not provided to five residents with complex medical needs on two occasions. The absence of the treatment nurse, lack of reassignment by the RN Supervisor, and incomplete coverage by the DON led to missed treatments, with no documentation of completion, refusal, or holding of care, contrary to facility policy.
Multiple residents with complex medical needs and high risk for pressure injuries did not receive physician-ordered daily wound care on two occasions due to staff absences and lack of reassignment, with no documentation or communication regarding the missed treatments.
Incomplete Post-Discharge Plan Documentation: A resident with schizoaffective disorder, anxiety disorder, anemia, and peripheral venous insufficiency had an incomplete post-discharge plan of care. The form was missing key required details, including who it was developed with, equipment needs, special observations, special training/instructions, post-discharge goals, and completed by/accepted by names and dates, and it was not signed by the resident as expected.
Inaccurate Assessment of Wandering Behavior: A resident admitted with schizoaffective disorder, anxiety disorder, anemia, and peripheral venous insufficiency was noted in a health status note to be monitored for wandering, but the MDS recorded no wandering behaviors. The DON reviewed the records and confirmed the discrepancy between the health status note and the MDS behavior section, while the resident was also documented as having moderate cognitive impairment and needing supervision/touching assistance for ADLs.
A resident with a documented history of sexually inappropriate behavior was not adequately supervised, and a roommate with severe cognitive and physical impairment was not protected from sexual abuse. Staff reported the resident pulling off his pants, rubbing his crotch, and attempting to touch the roommate while the roommate was in bed. The resident did not have an appropriate care plan on admission, and staff stated no IDT was completed for the earlier behavior incident and the interventions were not specific enough.
Failure to Timely Report Resident-to-Resident Sexual Abuse: A resident with severe cognitive and physical impairment was the target of sexual abuse by another resident with a documented history of sexually inappropriate behavior, poor impulse control, and prior psychiatric hold for danger to others. Staff observed the other resident touching himself and attempting to touch the resident's leg, but the incident was not reported to CDPH within the required 2-hour timeframe, and the DON and ADM confirmed it was not reported.
A resident who was cognitively intact but fully dependent on staff for care lent $3,000 to a CNA's friend, with only a small portion repaid. The CNA did not report this financial transaction, despite facility policies requiring staff to report suspected exploitation or misappropriation of resident property. Other CNAs and the social service designee confirmed that soliciting money from a resident is inappropriate and constitutes financial abuse.
A resident with end stage renal disease and depression experienced discomfort due to a room temperature of 84°F, which was above the facility's policy range. The resident reported feeling hot and uncomfortable, and the use of an electric fan provided only minimal relief. Multiple rooms were found to be above the recommended temperature range during the survey.
A facility failed to protect residents from physical abuse by another resident with schizoaffective disorder. The aggressive resident was not provided with a specific care plan, leading to incidents where he hit two different roommates, causing harm and distress. The facility did not implement its Abuse Prevention Program policy, resulting in inadequate management of the resident's behavior.
A resident with pneumonia and COPD did not receive necessary care and services according to professional standards. The facility failed to implement a comprehensive care plan for oxygen use and did not conduct routine resident checks. Vital signs were inaccurately documented, and the resident was found unresponsive and later pronounced dead. Interviews revealed discrepancies in care plan implementation and documentation practices.
The facility failed to provide necessary therapy services for two residents with limited ROM, leading to significant health issues. One resident experienced a decline in ROM in the left upper extremity, resulting in a contracture and a Stage IV pressure injury due to inconsistent RNA treatments and unreported refusals. Another resident faced a delay in RNA services for PROM and AFO application, posing potential injury risks. The facility's deficiencies in therapy services contributed to adverse outcomes and potential risks.
The facility failed to provide necessary respiratory care for two residents, as one resident's oxygen tubing was found on the floor and undated, while another resident's tubing was not changed weekly as required. Staff confirmed these practices posed infection control issues, and the facility's policies for oxygen administration and infection prevention were not followed.
The facility failed to timely initiate the process for appointing resident representatives for two residents unable to make medical decisions. One resident had severe cognitive impairments and physical disabilities, while another had multiple diagnoses affecting decision-making capacity. The Bioethics Committee initially managed care, but applications for conservators were delayed, with no specific guidance or timeline followed.
A resident, who was cognitively intact and capable of decision-making, was not included in care plan meetings at the facility, despite expressing concerns about premature discharge. The Social Services Director confirmed the lack of documentation of the resident's participation, contrary to the facility's policy encouraging resident involvement.
A resident with multiple health conditions, including blindness and hemiplegia, had their call light placed out of reach, contrary to their care plan and facility policy. This oversight was confirmed by the Infection Preventionist and acknowledged by the DON, highlighting a failure to ensure the resident could call for assistance when needed.
A resident with multiple health conditions was not provided with his preferred daily shave, as outlined in his care plan. Despite being able to communicate his needs, the facility only provided shaves twice a week on shower days. Staff interviews confirmed the oversight, acknowledging the resident's right to request a daily shave and the facility's failure to adhere to its policies on accommodating resident preferences.
A resident with severe cognitive impairments and hemiplegia repeatedly refused RNA treatments, which were not reported to the physician as required by facility policy. The resident's care plan included PROM exercises and a hand splint to prevent contractures, but refusals were not documented or communicated, leading to a Stage 4 pressure injury on the resident's hand.
A resident with multiple health conditions reported verbal harassment by the DON, but the facility failed to develop a care plan addressing the alleged abuse. Despite the resident's cognitive intactness and potential emotional distress, no care plan was initiated, contrary to facility policy requiring comprehensive, person-centered care plans.
A resident with multiple health issues was inaccurately assessed as low risk for falls due to errors in the fall risk assessment, which did not account for their medication use and medical history. This misclassification could have led to insufficient preventive measures, despite the care plan identifying the resident as high risk for falls.
A facility failed to provide and document necessary colostomy care for a resident, leading to potential complications. The resident, with a history of quadriplegia and diabetes, was readmitted without appropriate colostomy care orders. Observations showed the colostomy bag lacked date and time markings, and there was no documentation in the EHR. Staff were unaware of the facility's policy on documenting colostomy care, which could lead to infection control issues.
A resident with significant weight loss did not receive prescribed Magic Cup supplements twice daily with meals, and weekly weights were not documented as required. The resident, with a history of schizoaffective disorder and anemia, experienced severe weight loss. Staff confirmed the absence of the supplement on meal trays and missing weight records, indicating a lapse in care.
The facility failed to provide a Restorative Nursing Assistant (RNA) certificate for a sampled RNA, leading to an inability to verify the RNA's competency. The Director of Staff Development, who was new to the position, was unable to locate the certificate in the facility's files. Interviews with the Registered Nurse Consultant, Director of Nursing, and Administrator confirmed the lack of certification, which was necessary to demonstrate the RNA's ability to perform restorative care, as required by the facility's policy.
A LTC facility experienced a medication error rate of 22.22%, affecting three residents. Errors included omitted or late administration of vitamin D and artificial tears, and an attempt to administer a mixture of crushed medications without verifying compatibility. The errors were identified during a survey, highlighting lapses in medication administration protocols.
The facility failed to remove discontinued divalproex tablets from a medication cart, leading to potential overmedication of a resident. Additionally, dronabinol capsules were improperly stored at room temperature instead of being refrigerated, as required. These deficiencies in medication management could lead to adverse effects and reduced efficacy of treatments.
The facility failed to follow fortified diet guidelines during lunch preparation, affecting seven residents who required increased caloric intake. Dietary Aide (DA1) did not communicate fortified diet orders, leading Cook1 to omit necessary additions to meals. Interviews confirmed the oversight, and the Registered Dietitian emphasized the importance of fortified diets for residents experiencing weight loss.
The facility failed to provide the correct food texture for residents on modified diets, with 15 residents receiving improperly pureed corn salad and others receiving flaked fish instead of finely chopped or ground textures. This oversight could pose risks for residents with chewing and swallowing difficulties.
The facility failed to maintain safe food storage practices, with several items in the kitchen found without proper labeling or dating. Observations revealed undated sandwiches and salads in the refrigerator, and a bag of deli meat in the freezer without a label or date. Interviews with staff indicated a lack of adherence to facility policies on food labeling and storage, posing potential risks to residents.
The facility lacked a policy for its Bioethics Committee, affecting 13 residents who could not make medical decisions. The committee, including the Medical Director and Administrator, acted as responsible parties without formal guidance. Resident 19, with multiple diagnoses, was represented by the committee without documentation of a conservator application. Staff interviews confirmed the absence of specific guidance, leading to a deficiency in care.
The facility failed to ensure accurate documentation of medical records for seven residents, with identical vital signs recorded by the same LVN across multiple shifts. This issue was identified for residents with various medical conditions, including metabolic encephalopathy and schizophrenia. The DON acknowledged the identical records but did not classify them as falsification, despite the lack of variation in the documented vital signs. The facility's policy on routine resident checks contradicted the DON's statement, requiring documentation for each shift.
A resident with a history of aggression due to schizophrenia and mood disorder became physically aggressive towards another resident, resulting in a skin tear. The aggressive behavior was known to staff, who reported previous incidents. The facility's policy on abuse was not effectively implemented to prevent this incident.
A resident with severe cognitive impairments was moved to a different room without notifying their representative, violating facility policy. The social service assistant attempted to contact the representative but failed to document the attempt, leading to a lack of communication about the room change.
A cognitively impaired resident was left unattended and exposed in a hallway for nearly an hour, despite being within eyesight of multiple staff members. The resident, diagnosed with dementia, was observed crawling and lying on the floor without receiving assistance or comfort. The facility's staff failed to implement the resident's care plan, which required constant supervision, leading to a deficiency in care.
Two residents with severe cognitive impairments and physical limitations experienced unwitnessed falls, but the facility failed to conduct required PT evaluations to assess and address potential safety issues. Despite the facility's policy, no PT evaluations were performed, as confirmed by the DOR and DON.
A resident with schizophrenia and a history of wandering was not adequately monitored or provided with effective care plan interventions, leading to an incident where the resident entered another resident's room and caused physical harm. The facility's failure to implement individualized care plans and accurately document the resident's condition contributed to the deficiency.
A resident admitted with anxiety disorder and schizophrenia did not have a complete baseline care plan within 48 hours, as required by the facility's policy. The DON acknowledged that only the dietary section was completed, and the MDS Coordinator confirmed the plan was not finished, potentially affecting the resident's immediate care needs.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident 1 was admitted with muscle weakness and wasting, had no capacity to make medical decisions per the H&P, and required maximal assistance for oral hygiene, showers, and toileting hygiene. On 6/18/2026 at about 8:45 AM, a scream was heard from Resident 1’s room, and Resident 1 alleged that Resident 2 hit him on the head with an overhead table. Resident 1 was found bleeding with an approximately three-inch laceration to the left side of the skull and reported 3/10 pain. Resident 1 was transferred to a GACH after the incident. ED documentation described Resident 1 as bedbound and noted blunt trauma, a scalp laceration, and a closed head injury. The laceration was heavily contaminated, irrigated with saline, and repaired with two staples. During later interview, Resident 1 stated he was afraid when Resident 2, who was irritated, hit him on the head with the overhead table. Resident 2 had diagnoses including schizoaffective disorder, insomnia, and anxiety, and the record showed a history of aggressive and abusive behavior toward other residents. The care plan identified potential verbal and physical abusive behaviors and noted prior incidents including calling another resident names, threatening to beat that resident, and spitting on that resident. The facility moved Resident 2 to Resident 1’s room after those behaviors, and the DON stated Resident 2 required supervision to prevent further abuse of other residents. On the day of the incident, the behavior incident form stated Resident 2 said he pushed the overhead table and hit Resident 1 on the head, and the DON did not respond when asked whether staff provided supervision to prevent the assault.
Failure to Report, Investigate, and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program and Resident-to-Resident Altercations policies when Resident 2, who had diagnoses including schizoaffective disorder and parkinsonism and was later placed on 72-hour monitoring for verbal aggression and spitting, was not adequately managed after an altercation with Resident 3. On 6/15/2026, Resident 2 was documented as being irritated, calling Resident 3 names, threatening to beat Resident 3 up, and spitting on Resident 3, with the spit landing on Resident 3’s shirt. The facility moved Resident 2 to another room, but the record showed the 72-hour monitoring documentation was incomplete, with no note covering the final 11 hours of the ordered monitoring period. The facility also failed to report and investigate the abuse allegations involving Resident 2 and Resident 3. During interview, the DON and LVN1 stated that spitting was not abuse and that there was no need to report the incident as abuse. The DON stated she did not report the incident to the Ombudsman, local police, or CDPH because spitting and name calling were not considered abuse. Later, LVN1 used a Google search and stated that spitting at another resident was considered physical abuse, and the DON stated the physical abuse between Resident 2 and Resident 3 should have been reported and investigated. The facility’s policy stated that all altercations, including those that may represent resident-to-resident abuse, were to be investigated and reported. The facility further failed to protect Resident 1, who was bedbound and dependent on staff for multiple activities of daily living, from physical abuse by Resident 2. On 6/18/2026, Resident 1 alleged that Resident 2 hit him on the head with an overhead table, causing a laceration and bleeding. Resident 1 was transferred by emergency services to a general acute care hospital and was diagnosed with blunt trauma, closed head injury, and scalp lacerations. The record also showed that Resident 2 had been moved into Resident 1’s room after the earlier altercation with Resident 3, and the DON did not respond when asked whether supervision had been provided to prevent Resident 2 from hitting Resident 1. The report also states that staff were not able to identify all types of abuse, and that Resident 1 and Resident 3 were not protected from abuse from Resident 2.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report and investigate an allegation of physical and verbal abuse involving two residents, and failed to ensure staff could identify all types of abuse. Resident 2 was admitted with diagnoses including homelessness, schizoaffective disorder, and parkinsonism. The resident’s care plan documented intermittent yelling, agitation, restlessness, attention seeking, refusal of PRN anti-anxiety medication, and a need for psychiatric consultation and close monitoring to prevent harm to self and others. A later care plan also identified potential verbally and physically abusive behaviors related to ineffective coping skills, poor impulse control, and a history of homelessness. On 6/15/2026 at 9:24 AM, an SBAR documented that Resident 2 was irritated, called Resident 3 names, threatened to beat Resident 3 up, and spit at Resident 3, with the spit landing on Resident 3’s shirt. The SBAR also stated Resident 2 was verbally aggressive toward staff and Resident 3, and the facility moved Resident 2 to another room to avoid future issues. Resident 2 was then placed on 72-hour monitoring because of the room change due to verbal aggression and spitting on a roommate, but the monitoring record did not include the final 11 hours of the ordered monitoring period. During interviews, the DON and LVN1 stated that spitting was not abuse and that there was no need to report the incident as abuse. The DON stated she did not report the incident to the Ombudsman, local police, or CDPH because spitting and name calling were not considered abuse. Later, LVN1 used Google and stated that spitting at another resident was considered physical abuse, and the DON stated the physical abuse between the two residents should have been reported and investigated. The facility’s Abuse Prevention Program policy stated residents had the right to be free from abuse and that allegations of abuse were to be investigated and reported within required federal timeframes.
Unsafe Transfer During Return From Pass
Penalty
Summary
The facility failed to ensure safe transfer assistance and supervision for a resident with dementia, cerebral infarction, muscle weakness, abnormal posture, neuralgia, mood dysregulation disorder, and anxiety. The resident’s MDS showed moderate impaired cognition and dependence on staff for multiple activities of daily living, including maximal assistance for toileting, bathing, dressing, footwear, and toilet transfer, and partial assistance for eating, oral hygiene, personal hygiene, bed mobility, sit-to-stand, and chair/bed transfers. The care plan identified the resident as at risk for accidents and falls and directed staff to assist with all transfers as needed, eliminate hazards, and provide safety instruction to the resident and family regarding transfers when appropriate. The resident’s fall risk assessment identified moderate fall risk due to disoriented level of consciousness, a history of falls, being chair bound, decreased muscular coordination, balance problems, and use of narcotics, psychotropics, and sedatives. The care plan for musculoskeletal complications also directed staff to assist with supportive devices and educate family/caregivers on safety measures to reduce fall risk. The facility’s policy titled Assistive Devices and Equipment, dated 1/15/2026, required family members to be trained on how to assist and safely transfer the resident in and out of a wheelchair. On 6/2/2026, when the resident returned from out of pass with the family member, the resident was transferred from a car to a wheelchair outside the facility. The fall incident report stated the resident slid off the wheelchair during the transfer. The family member stated that CNA 1 and the family member assisted with the transfer instead of two trained facility staff members, that the resident was not properly positioned in the wheelchair, and that the facility had not instructed or educated the family member on how to properly perform the surface transfer. The RN supervisor stated the resident required a 2-person assist, acknowledged the resident’s poor posture and physical limitations, and stated the resident was probably not seated correctly in the wheelchair. CNA 2 stated the family member assisted CNA 1 during the transfer and that the resident slid off the wheelchair.
Controlled Medication Counts Did Not Match Records
Penalty
Summary
The facility failed to accurately account for four doses of controlled medications in Medication Cart 1, affecting Resident 18, Resident 29, and Resident 61. During observation and concurrent interview, discrepancies were identified between the Narcotic and Hypnotic Record and the medication cards for lorazepam 0.5 mg, clonazepam 0.5 mg, phenobarbital 64.8 mg, and hydrocodone/apap 5/325 mg. In each case, the record showed one more dose remaining than was actually present in the medication card. During the interview, LVN 2 stated that she administered the missing controlled medications for the three residents on 4/1/2026 but did not sign the corresponding Narcotic and Hypnotic Records because she was distracted by other tasks. LVN 2 stated she was required to sign the record immediately after administration to maintain accountability of controlled medications and help prevent medications from being administered too often. The facility policy on Controlled Substances stated that upon administration, the nurse is responsible for recording the time of administration, quantity remaining, and signature of the nurse administering the medication.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5%, with 5 errors out of 27 opportunities for an overall error rate of 18.52%. The errors affected three residents observed during medication administration and involved incorrect medications, incorrect formulation, incorrect strength, and failure to follow a physician order for administration with food. The facility policy stated medications are to be administered as prescribed, within the required time frame, and with the label checked three times to verify the right resident, medication, dosage, time, and route. For one resident with a history of hemiplegia and hemiparesis following cerebral infarction, the nurse prepared and administered senna/docusate 8.6/50 mg even though the order was for senna 8.6 mg twice daily for constipation. The nurse stated she administered the combination product instead of senna alone and failed to check the label against the order before giving the medication. For another resident with type 2 diabetes, the nurse prepared senna/docusate and metformin 1000 mg; the resident took the metformin but refused the senna/docusate. The order required metformin 1000 mg twice daily with meals, and the nurse stated the medication was not given with a meal and was administered later than scheduled. For a third resident with cervical spondylosis and no capacity to make medical decisions, the nurse prepared a multivitamin with minerals and a lidocaine 5% patch. The order was for a multivitamin without minerals and a lidocaine 1.8% patch. The nurse stated he administered the wrong multivitamin formulation and the wrong lidocaine strength, and that the 5% patch came from another resident’s supply. He also stated he failed to check the prescription label and the ordered strength and formulation before administration.
Failure to Follow Pureed Texture and Renal Diet Menu
Penalty
Summary
The facility failed to follow the standardized recipe and IDDSI Level 4 requirements for pureed bread served on the lunch tray line. During observation, the pureed bread on the steam table appeared lumpy, dry, and not smooth. In a concurrent interview and taste test, the Dietary Supervisor stated the bread was grainy, dry, not smooth, chewy, and sticky, and that it needed to be blended longer and made moister. The Registered Dietitian stated the bread was not smooth because whole wheat bread had been used, and that puree texture should not require chewing and must be smooth. Cook1 also stated the bread was not smooth and lumpy because whole wheat bread had been used and that it should have been blended longer with more liquid. The facility’s recipe for Pureed (IDDSI Level 4) breads, cakes, cookies, pancakes, and other bread products stated the finished item should be smooth and free of lumps, hold its shape, and not be too firm or sticky. The IDDSI guidance reviewed by surveyors stated Level 4 pureed foods should fall off a spoon in a single spoonful, hold shape, and have no lumps or stickiness. The observed pureed bread did not match those requirements, and the Dietary Supervisor stated that when pureed texture is not prepared correctly it could be a choking risk for residents on a pureed diet. The facility also failed to follow the lunch menu and recipe for the renal diet. The menu listed turkey pattie with gravy and wheat pasta with margarine, but during tray line service Cook1 served chicken nuggets and white rice instead. Cook1 stated the kitchen did not have turkey patties, chose chicken nuggets because most residents preferred them, and forgot that whole wheat pasta was on the menu. Cook1 stated the menu was not followed and that the DS or RD was not informed when ingredients were missing. The DS and RD stated staff should inform them when ingredients are missing so proper menu adjustments can be made, and the DS stated renal diets are ordered by doctors and it is important to follow them as written.
Unsafe Dry Food Storage Practices
Penalty
Summary
Safe and sanitary food storage practices were not maintained in the kitchen during observation and interview. One scoop was found stored inside a bulk rice container with the handle touching the rice. During the concurrent interview, the Dietary Supervisor stated the scoop should not have been inside the bin and on the food because the handle was not clean and could contaminate the rice. The Dietary Supervisor also stated the scoops were supposed to be hanging on a holder inside the bins. Bulk dry foods, including oatmeal, rice, and flour, were observed stored in large bins lined with plastic bags. During interview, the Dietary Supervisor stated the liners were regular trash bags and were not food grade, and that kitchen staff used the same bags for trash and stored them in the chemical room. The Dietary Supervisor stated the bulk food should be stored directly in the plastic bins that were easy to clean and sanitize after use. The facility policy required dry bulk foods to be stored in seamless metal or plastic containers with tight covers or in bins that are easily sanitized, and required food grade bags if plastic bags were used.
Antipsychotic Order Lacked Specific Behavior Manifestation
Penalty
Summary
The facility failed to ensure one of five sampled residents was free from chemical restraint concerns when Resident 3’s physician order for Haloperidol (Haldol) 10 mg at bedtime did not specify a resident-specific behavior manifestation. Resident 3 was admitted with diagnoses including mood affective disorder, schizoaffective disorder, and anxiety, and the MDS dated 2/25/2026 indicated severely impaired cognition, substantial to maximal assistance with eating and oral hygiene, and dependence on staff for toileting hygiene, bathing, dressing, footwear, and personal hygiene. The MDS also indicated the resident was receiving antipsychotic medication. Resident 3’s psychotherapeutic drug informed consent form documented surrogate consent for Haldol 10 mg at bedtime for schizophrenia manifested by auditory hallucinations. The order summary report showed a physician order dated 4/1/2026 for Haldol 10 mg at bedtime for responding to internal stimuli related to schizoaffective disorder. The MAR dated 3/27/2026 through 3/31/2026 showed five doses of Haldol 10 mg at bedtime, and it also documented three instances of responding to internal stimuli on the evening shift on 3/31/2026. During interviews and record review, LVN 1 stated she was not sure what responding to internal stimuli meant and said it would have been easier to monitor a more specific behavior such as yelling or talking to herself. RN 1 stated the nurses were not monitoring for specific behavior and that responding to internal stimuli was not a specific behavior. RN 2 stated the manifestation was broad and could be interpreted differently by licensed nurses, which could lead to inaccurate monitoring. The DON stated the manifestation was not specific enough to be monitored and should have been a more specific behavior such as auditory hallucinations. The facility’s antipsychotic medication policy stated residents should only receive antipsychotic medications when necessary for specific conditions and that staff should gather and document information to clarify behavior, mood, function, medical condition, specific symptoms, and risks.
Tube Feeding Care Plan Not Updated After New Physician Order
Penalty
Summary
The facility failed to update and revise Resident 5’s tube feeding care plan after a new physician order was received for Glucerna 1.2 via g-tube at 70 ml/hr for 20 hours. Resident 5 was admitted with diagnoses that included adult failure to thrive, dysphagia, and gastrostomy, and the MDS dated 3/7/2026 indicated severe cognitive impairment and dependence on staff for multiple activities of daily living, including oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. The care plan dated 9/9/2025 identified tube feeding related to dysphagia and listed Jevity 1.5 at 55 ml/hr for 20 hours as the intervention. A review of the Order Summary Report showed a physician order dated 3/27/2026 for Glucerna 1.2 via the g-tube at 70 ml/hr for 20 hours for a total of 1400 ml. During interview and record review, RN 1 and the DON both stated the tube feeding care plan still reflected Jevity 1.5 at 55 ml/hr and had not been revised to match the current order for Glucerna 1.2 at 70 ml/hr. The DON stated the care plan should have been updated when the new physician order was received and that the care plan needed to reflect Resident 5’s current plan of care.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to ensure the Dialysis Communication Record was completed for a resident who received dialysis every Monday, Wednesday, and Friday. The resident was re-admitted with diagnoses including ESRD and dependence on renal dialysis. The resident's MDS dated 3/1/2026 indicated the resident was cognitively intact and required varying levels of assistance with eating, oral hygiene, dressing, personal hygiene, toileting hygiene, showering/bathing, and footwear, and also indicated the resident was receiving dialysis treatment. The resident had a physician order dated 3/2/2026 for dialysis at the dialysis center every Monday, Wednesday, and Friday. The facility's Dialysis Communication Record form was intended to be completed by a licensed nurse before dialysis, by the dialysis center during dialysis, and by a licensed nurse after dialysis. Review of the resident's Dialysis Communication Records dated 3/9/2026 through 4/1/2026 showed the post dialysis assessment was not completed on 3/11/2026, 3/16/2026, and 3/20/2026. Those records did not include documentation of the resident's cognitive status, vital signs, dialysis access site, or breathing patterns in the post dialysis section. There were also no Dialysis Communication Records for the resident on 3/23/2026, 3/25/2026, 3/27/2026, and 3/30/2026. RN 2 confirmed the records were not completed post dialysis on 3/11/2026, 3/16/2026, and 3/20/2026 and stated there was no record for the later dialysis sessions. The DON also confirmed the missing post dialysis assessments and the absent records, and stated the form had to be completed before, during, and after each dialysis session. The facility policy titled Hemodialysis Access Care stated the general medical nurse should document the catheter location, dressing condition, whether dialysis was done during the shift, any report from the dialysis nurse post-dialysis, and post-dialysis observations.
Improper Storage of Refrigerated Medications
Penalty
Summary
The facility failed to store unopened insulin lispro in the refrigerator on Medication Cart 2 and failed to store gabapentin solution in the refrigerator on Medication Cart 1, as required by the manufacturers' instructions. During a concurrent observation and interview, one unopened insulin lispro pen was found stored at room temperature without a labeled open date. The product labeling indicated unopened insulin lispro pens had to be refrigerated, and the LVN stated the pen was unopened and should have been stored in the refrigerator. During a separate observation and interview, one prescription bottle of gabapentin solution 250 mg per 5 ml was found stored at room temperature in Medication Cart 1. The product and pharmacy labeling indicated the gabapentin solution had to be refrigerated, and the LVN stated it was being stored in the cart at room temperature and did not know how long it had been there. The facility policy stated that medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured locations.
Failure to Communicate Pre-Appointment Instructions for CT Angiogram
Penalty
Summary
The facility failed to ensure that one cognitively intact resident with ESRD, dependence on renal dialysis, hemiplegia, hemiparesis, hypertension, and hepatic failure was made aware of the pre-appointment instructions for a scheduled CT angiogram and cardiac echocardiogram. The physician order dated 2/18/2026 required the resident to fast for four hours before the appointment, avoid caffeine for 24 hours before the appointment, and have dialysis scheduled within four to five hours after the appointment. On 3/30/2026, the resident went to dialysis before the appointment and had eaten food before arriving for the CT angiogram. The resident stated that nursing staff did not communicate any information or instructions about the appointment and that the resident believed the CT angiogram was supposed to occur before dialysis. Because the resident had eaten and had dialysis before the appointment, the CT angiogram could not be completed and the appointment had to be rescheduled to 4/15/2026. The Social Services Director and RN 2 both stated they were responsible for communicating the appointment instructions to the resident and confirmed that the fasting and dialysis instructions were not communicated. The DON stated the resident did not have the CT angiogram and cardiac echo as scheduled because the appointment instructions were not communicated and that the dialysis was not rescheduled for later in the day. The facility policy stated social services would coordinate resident referrals and collaborate with nursing staff to arrange physician-ordered services.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure that a working call system was within reach in a resident’s bathroom and bathing area, as well as within reach while the resident was in bed. Resident 68 was admitted on 2/7/2025 and readmitted on 3/13/2026 with diagnoses including spondyloarthropathy of the spine, dementia, and major depression disorder. The resident’s fall risk assessment identified a moderate risk for falls, the MDS dated 2/4/2026 showed the resident required maximum assistance with ADLs, and the care plan revised on 3/22/2026 directed that the call light be kept within easy reach and answered promptly. During interview, Resident 68 stated she was unable to get up or reposition herself without assistance and relied on the call light to ask for help, but could not find it after staff changed her bed linens earlier that day. During concurrent observation, the call light cord was clipped to the bedsheet at the head of the bed and was dangling off the left side of the bed, and CNA 1 stated it was not within the resident’s reach. LVN 4, RN 2, and the DON each stated that call lights should be within residents’ reach, and the DON reviewed the facility policy titled, Answering the Call Light, which stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Failure to Timely Notify Physician of Ongoing Psychotropic Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a resident’s physician of ongoing refusals of a prescribed psychotropic medication, Depakote, ordered for paranoid schizophrenia. The resident was admitted with diagnoses including paranoid schizophrenia, psychosis, and muscle weakness, and had a physician’s order for Depakote 125 mg twice daily for schizophrenia. The resident’s care plan, initiated and later revised, documented use of Depakote for paranoid schizophrenia, with interventions to assess daily for behaviors, notify the physician if the medication could be reduced, and monitor and report behaviors monthly to the physician/psychiatrist. The MDS indicated the resident was cognitively intact and required set-up assistance with ADLs. Review of the MAR for January showed the resident repeatedly refused Depakote at scheduled 9 a.m. and 5 p.m. doses on numerous days throughout the month, including multiple consecutive refusals. Facility staff, including an LVN, stated that when the resident refused medications, they would offer them twice and that the physician should be notified when refusals occurred. The RN supervisor acknowledged the resident had been refusing Depakote and that the medication was for control of delusions. The DON stated that refusal of Depakote would exacerbate the resident’s condition and confirmed there was no documentation that the primary physician or psychiatrist had been notified of the refusals prior to a change-of-condition note created on January 30, when the physician was finally notified. The facility’s policy on change in condition required physician notification when a resident refused treatment or medications two or more consecutive times, which was not followed in this case.
Failure to Provide Physician-Ordered Wound Care and Treatment
Penalty
Summary
The facility failed to implement physician-ordered daily wound treatments for five residents on two separate days. These residents had significant medical needs, including quadriplegia, colostomy status, open wounds, dementia, contractures, hemiplegia, hemiparesis, and severe cognitive impairment. Physician orders for wound care, skin management, and monitoring of specialized equipment such as low air loss mattresses and casts were not carried out as scheduled. Documentation confirmed that the required treatments were not provided, and there was no record of treatments being completed, refused, or held. Interviews with facility staff revealed that the treatment nurse, who was responsible for administering these treatments, was absent on one of the days and did not report missed treatments on another. The Registered Nurse Supervisor, who was aware of the absence of a treatment nurse, did not reassign the responsibility to another licensed nurse or ensure that the treatments were completed. The Director of Nursing acknowledged that she attempted to provide treatments herself but was unable to complete all required treatments for residents with extensive or complex wound care needs. Facility policy required that medications and treatments be administered only upon written physician orders and that licensed nurses demonstrate competency in providing care as identified in resident assessments and care plans. The failure to follow these orders and policies resulted in residents not receiving necessary wound care and monitoring as prescribed by their physicians.
Failure to Provide Physician-Ordered Wound Care for Multiple Residents
Penalty
Summary
The facility failed to implement physician-ordered daily wound care treatments for five residents who were at risk for or had existing wounds and pressure injuries. On two specific dates, the Treatment Administration Record (TAR) showed that required wound care was not provided as scheduled for these residents. The affected individuals had complex medical histories, including quadriplegia, colostomy, contractures, dementia, and existing pressure injuries, and were dependent on staff for most activities of daily living. Physician orders included specific wound care regimens such as cleansing with normal saline, application of Santyl collagenase ointment, use of barrier creams, and monitoring of low air loss mattresses, all of which were not carried out on the identified dates. Interviews with facility staff revealed that the treatment nurse, who was responsible for administering these treatments, was absent on one of the days and did not complete or document the required care on another. The Registered Nurse Supervisor, who was present during one of the shifts, acknowledged that no alternative licensed nurse was assigned to complete the treatments, nor was there any communication regarding the missed care. The Director of Nursing confirmed that despite being aware of the staffing gap, she was unable to ensure all necessary treatments were provided, resulting in multiple residents missing their prescribed wound care. Facility policy required that medications and treatments be administered only upon written physician orders, and that wound treatments be managed according to clinical protocols. The failure to follow these orders and protocols led to a lack of daily wound care for residents with significant risk factors for skin breakdown and delayed healing. There was no documentation of treatments being completed, refused, or held, and no evidence that missed treatments were reported to the physician or other responsible parties.
Incomplete Post-Discharge Plan Documentation
Penalty
Summary
The facility failed to ensure that the discharge summary and post-discharge plan policy was followed for one resident. During interview and record review, Resident 1’s post-discharge plan of care was found to be incomplete and not signed. The document did not identify who the plan was developed with and was missing equipment needs, special observations, special training/instructions, post-discharge goals, and the completed by and accepted by names and dates. Registered Nurse Supervisor 1 verified the document was incomplete and stated he was unsure who filled it out, although he believed it was typically done by the night shift RN, and noted that the resident should have signed it. Resident 1’s record showed admission to the facility with diagnoses including schizoaffective disorder, anxiety disorder, anemia, and peripheral venous insufficiency. The History and Physical dated 5/14/25 indicated the resident had capacity to understand and make decisions, while the MDS dated 5/17/25 indicated moderate cognitive impairment and a need for supervision or touching assistance with ADLs. The facility policy titled Discharge Summary and Plan stated that when discharge is anticipated, a discharge summary and post-discharge plan are to be developed by the IDT with assistance from the resident and family and are to include the resident’s stated discharge goals, caregiver/support availability, IDT support for transition, and resident or representative involvement in the planning process.
Inaccurate Assessment of Wandering Behavior
Penalty
Summary
The facility failed to accurately assess wandering behaviors for one resident. The resident was admitted with diagnoses including schizoaffective disorder, anxiety disorder, anemia, and peripheral venous insufficiency. The resident’s H&P dated 5/14/25 indicated the resident had capacity to understand and make decisions, and a health status note dated 5/16/25 indicated the resident was on monitoring for behavior of wandering. The resident’s MDS dated 5/17/25 indicated moderate cognitive impairment and that the resident required supervision/touching assistance for ADLs, but it also indicated the resident did not have any wandering behaviors. During a concurrent interview and record review, the DON reviewed the health status note and MDS behavior section and confirmed there was a discrepancy in the assessment, stating she was not aware but the resident was new so those behaviors are not uncommon. The facility’s policies on wandering and resident assessment were reviewed and described identifying residents at risk of unsafe wandering and completing a comprehensive assessment using the MDS.
Failure to Supervise Resident With Sexual Behaviors and Protect Roommate From Abuse
Penalty
Summary
The facility failed to supervise and monitor a resident with a documented history of sexually inappropriate behavior, including pulling off his pants, self-pleasuring throughout the day, and rubbing his genitals in the presence of others. The resident had diagnoses including other encephalopathy, psychotic disturbance, and mood disturbance, and records showed he did not have capacity to understand and make decisions. His hospital discharge summary and admission history documented prior sexually inappropriate conduct, including attempting sexual activity with a male roommate and frequent self-touching. The facility also failed to protect another resident from sexual abuse by the same resident. A CNA reported that the resident had inappropriately attempted to touch the roommate's leg while the roommate was in bed. Another staff member later stated a CNA witnessed the resident with one hand underneath the roommate's blanket while the resident had the other hand down his own pants while masturbating. The roommate had severe cognitive impairment, did not have capacity to understand and make decisions, and was dependent on staff for toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers. The resident with the inappropriate sexual behavior did not have a care plan addressing that behavior upon admission, despite the facility's policy requiring a comprehensive, person-centered care plan within seven days of the assessment. The first care plan addressing the behavior was initiated after an incident of pulling off his pants in the hallway. That care plan included general interventions such as providing a safe environment, teaching safe practice, and transferring to the hospital for psychiatric evaluation. After the later incident involving the roommate, another care plan was initiated for altered behavior involving invading the roommate's space and rubbing his crotch, with interventions to monitor behavior, provide redirection, ensure environmental safety, document recurrent or escalating behaviors, and seek psychiatric evaluation. Staff and leadership stated that no interdisciplinary team was conducted for the earlier incident and that the interventions were not specific enough.
Failure to Timely Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report within 2 hours an allegation of resident-to-resident sexual abuse involving two residents. On 10/29/2025, one resident was observed with one hand down his pants touching himself while using his other hand to try to touch the other resident's leg. The report states this incident was considered sexual abuse and was not reported to the California Department of Public Health (CDPH) within the required time frame. The resident who was the target of the incident had diagnoses including metabolic encephalopathy, unspecified dementia, hemiplegia, hemiparesis following cerebral infarction, and muscle weakness. His MDS indicated severely impaired cognition, lower extremity impairment, dependence on staff for toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and that he did not walk. His H&P stated he did not have the capacity to understand and make decisions. The resident who initiated the behavior had diagnoses including other encephalopathy, psychotic disturbance, and mood disturbance. Records showed a prior 5150 hold for danger to others and documented a history of sexually inappropriate behavior, including pulling his pants down, attempting sexual activity with a male roommate, and frequently touching himself. Staff interviews confirmed the incident was sexual abuse and should have been reported to CDPH within 2 hours, but the DON and Administrator stated it was not reported to CDPH.
Failure to Prevent and Report Financial Exploitation of a Resident by Staff
Penalty
Summary
The facility failed to ensure that services provided to a resident met professional standards of practice when a certified nursing assistant (CNA) and the CNA's friend solicited and received money from a resident. The resident, who was cognitively intact but totally dependent on staff for most activities of daily living due to quadriplegia, diabetes mellitus, and anemia, lent $3,000 to the CNA's friend, of which only $200 was repaid. The incident was not reported by the CNA, despite facility policies requiring staff to report suspected exploitation, theft, or misappropriation of resident property. Interviews with other CNAs and the social service designee confirmed that asking for money from a resident is considered inappropriate and constitutes financial abuse. The facility became aware of the situation when the resident's next of kin reported the financial transaction. The facility's policies and procedures, reviewed prior to the incident, clearly outlined expectations for staff to report such incidents and to uphold ethical standards in their interactions with residents.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable room temperature for one of four sampled residents, resulting in a room temperature of 84°F, which exceeded the facility's policy range of 71°F to 81°F. This was confirmed through observation, interview, and record review. The resident, who was cognitively intact and required moderate assistance with activities of daily living, reported feeling hot and uncomfortable in his room. He used an electric fan, but stated it only helped a little to cool down the room. On the day of the survey, the maintenance supervisor measured the temperatures in several rooms, all of which were found to be 84°F. The facility's policy and procedures, reviewed earlier in the year, specified that residents should be provided with a comfortable and safe temperature within the stated range. The resident's medical history included end stage renal disease and depression, and he had been admitted and re-admitted to the facility prior to the incident.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, specifically involving two residents who were subjected to physical aggression by a third resident diagnosed with schizoaffective disorder bipolar type. The facility did not implement its Abuse Prevention Program policy to protect residents from abuse by others, including fellow residents. This resulted in incidents where the aggressive resident hit two different roommates on separate occasions, causing physical harm and psychological distress. The aggressive resident, who had a history of combative and agitated behavior, was not provided with a specific care plan addressing his schizoaffective disorder. Despite having a physician's order for antipsychotic medication and a need for behavior monitoring, the facility did not develop a care plan with interventions to manage the resident's behavior. This lack of a tailored care plan contributed to the resident's aggressive actions, as there were no specific strategies in place to monitor and mitigate his behavior effectively. The incidents occurred when the aggressive resident was moved to different rooms after altercations with roommates. The facility's failure to verify the resident's diagnosis and create an appropriate care plan led to inadequate management of his behavior, resulting in physical confrontations with his roommates. The facility's inaction in developing a comprehensive care plan and implementing its abuse prevention policy increased the risk of harm to other residents.
Failure to Implement Care Plans and Accurate Documentation Leads to Resident's Death
Penalty
Summary
The facility failed to provide necessary care and services to Resident 77, who had diagnoses of pneumonia and chronic obstructive pulmonary disease (COPD), in accordance with professional standards of practice. The facility did not implement the Speech Therapy at Risk for Aspiration care plan interventions, which included oral pharyngeal stimulation and exercises. Additionally, the facility did not develop a comprehensive, person-centered care plan that included the physician's order for Resident 77 to receive oxygen at two liters per minute via nasal cannula as needed for shortness of breath related to COPD. Furthermore, the facility did not ensure that Resident 77's vital signs documented by the Licensed Vocational Nurse (LVN 4) were accurate on multiple dates. The facility also failed to implement its policy and procedure titled Routine Resident Checks, as there was no routine resident check at least once per each 8-hour shift for Resident 77. The last skilled nursing assessment was documented at 1:45 PM, and Resident 77 was found unresponsive in his room the following morning at 7:32 AM. Cardiopulmonary Resuscitation (CPR) was initiated, and Emergency Medical Services (EMS) were called, but Resident 77 was pronounced dead by the paramedics at 8:08 AM. The facility's documentation practices were called into question, as vital signs for Resident 77 and five additional residents were documented as exactly the same across different shifts, raising concerns about the accuracy and reliability of the records. Interviews with facility staff revealed discrepancies in the implementation of care plans and documentation practices. The Director of Nursing (DON) acknowledged the issues with vital sign documentation but did not consider it falsification of records. The Minimum Data Set Nurse (MDSN) confirmed that a care plan for oxygen use should have been initiated for Resident 77. The facility's policies and procedures for routine resident checks and documentation were not followed, contributing to the lack of timely assessments and accurate records for Resident 77. These deficiencies in care and documentation ultimately led to the resident being found unresponsive and subsequently pronounced dead.
Failure to Provide Therapy Services Leads to Severe Contracture and Pressure Injury
Penalty
Summary
The facility failed to provide necessary therapy services for two residents with limited range of motion (ROM), leading to significant health issues. Resident 48, who had a history of hemiplegia and hemiparesis following a cerebral infarction, experienced a decline in ROM in the left upper extremity. Despite a physician's order for Restorative Nursing Aide (RNA) services to perform passive range of motion (PROM) exercises and apply a left resting hand splint, these treatments were inconsistently provided or refused by the resident. The facility did not report these refusals or missed treatments to the charge nurse or therapy staff, nor did they conduct a nursing assessment following the refusals, as required by facility policy. Resident 48's condition worsened over several months, resulting in a contracture of the left hand into a fisted position. This contracture led to the development of a Stage IV pressure injury on the left middle finger, which was identified in January 2025. The facility's failure to provide consistent RNA treatments and to address the resident's refusals contributed to this severe outcome. Additionally, the facility did not conduct an Occupational Therapy (OT) evaluation after identifying the decline in ROM, which could have provided alternative interventions to prevent the contracture and subsequent pressure injury. Resident 6 also experienced a delay in the start of RNA services for PROM and the application of left ankle foot orthotics (AFO), as ordered by physical therapy. This delay had the potential to cause injury due to the improper application of the AFO. The facility's lack of timely and appropriate therapy services for both residents highlights significant deficiencies in their care, leading to adverse health outcomes for Resident 48 and potential risks for Resident 6.
Failure to Provide Safe Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents, Resident 55 and Resident 291, as observed during a survey. Resident 55, who was admitted with chronic obstructive pulmonary disease (COPD) and anemia, had a physician's order for oxygen therapy via nasal cannula as needed. During an observation, Resident 55's oxygen cannula tubing was found on the floor, undated, and dirty, which was confirmed by a Certified Nursing Assistant (CNA) and other staff members. The facility's staff acknowledged that using tubing from the floor posed an infection control issue and could lead to respiratory infections. Resident 291, admitted with acute respiratory failure and hypoxia, was observed using oxygen therapy continuously. The oxygen tubing for Resident 291 was dated 1/29/2025, indicating it had not been changed weekly as required by the facility's policy. The Infection Preventionist (IP) confirmed that the tubing should have been changed on 2/5/2025, and the Director of Nursing (DON) acknowledged the potential for infection control issues if the tubing was not changed weekly. The facility's policies and procedures for oxygen administration and infection prevention were reviewed, indicating that oxygen cannula and tubing should be changed every seven days or as needed, and that oxygen humidifiers should be dated and changed after 24 hours. The failure to adhere to these policies resulted in deficiencies in providing safe and appropriate respiratory care for the residents, potentially exposing them to complications associated with oxygen therapy.
Delayed Appointment of Resident Representatives
Penalty
Summary
The facility failed to timely initiate the process for appointing a resident representative for two residents who were unable to make medical decisions. Resident 48 was admitted with severe cognitive impairments and physical disabilities, including hemiplegia and hemiparesis following a cerebral infarction. Despite these conditions, the facility did not start the process for appointing a conservator until two months after the resident's admission. The Social Services Director acknowledged that the process should have begun earlier when it was clear that Resident 48 could not make decisions and had no known family. Similarly, Resident 19 was admitted with multiple diagnoses, including metabolic encephalopathy, schizophrenia, dementia, and bipolar disorder, which impaired the resident's decision-making capacity. The Bioethics Committee initially acted as the responsible party for Resident 19, but the application for a conservator was not submitted until four months after admission. The facility's Medical Director and Social Services Director confirmed that the Bioethics Committee was responsible for managing care until a conservator was appointed, but there was no specific timeline for this process. The facility's policy titled 'Resident Representative' did not provide guidance on the role of the Bioethics Committee or the process for appointing a conservator. Interviews with facility staff revealed that there was no specific guidance or timeline followed by the Bioethics Committee, leading to delays in appointing a responsible party for residents unable to make decisions. This deficiency highlights the facility's failure to ensure timely initiation of the process for appointing a resident representative, potentially leaving residents without a responsible party to assist in making medical decisions.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 62, participated in care plan meetings, which are essential for discussing care and discharge goals. Resident 62, who was cognitively intact and capable of making decisions, expressed concerns about being discharged prematurely and not being involved in the care planning process. Despite being aware of the meetings, Resident 62 was not included in them, as confirmed by the Social Services Director (SSD) during a review of the resident's records. The SSD acknowledged the absence of documentation indicating Resident 62's participation in the care plan meetings, despite the facility's policy encouraging resident involvement. The facility's policy, last revised in January 2025, emphasizes the importance of resident participation in care planning to address concerns and set goals. The lack of involvement of Resident 62 in these meetings represents a failure to uphold the resident's right to be an active participant in their care, as outlined in the facility's procedures.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the residents, identified as Resident 51. This resident was readmitted to the facility with multiple diagnoses, including HIV, epilepsy, blindness, and hemiplegia, and required substantial assistance for daily activities. The resident's care plan specifically indicated the need for the call light to be within reach to prevent injury and ensure prompt assistance. However, during an observation, the call light was found on the bedside dresser, out of the resident's reach. The Infection Preventionist confirmed the call light was not accessible to the resident and moved it to the bed. The Director of Nursing acknowledged that call lights should be within reach to allow residents to call for help, and failure to do so could delay care. The facility's policy on answering call lights emphasized the importance of having the call light within easy reach of residents, especially those confined to bed or a chair.
Failure to Honor Resident's Preference for Daily Shave
Penalty
Summary
The facility failed to respect a resident's right to self-determination and choice by not providing a daily shave as preferred by the resident. The resident, who was admitted with multiple diagnoses including seizures, COPD, muscle weakness, bipolar disorder, anxiety, neuropathy, exposure to war, abnormal posture, and a history of traumatic brain injury, expressed his preference for a daily shave. Despite having the capacity to understand his medical condition and rights, and being assessed as able to make himself understood, the facility only provided shaves twice a week on shower days, contrary to the resident's care plan which specified a daily shave. Interviews with facility staff, including a CNA, LVN, RN, and the DON, confirmed that the resident's preference for a daily shave was not being met. The CNA stated that shaves were only given on shower days and would only provide additional shaves if time permitted. The LVN and RN acknowledged the resident's right to request a daily shave and recognized that the facility was not adhering to the care plan. The DON also confirmed the oversight and noted that the facility was not following the resident's rights as outlined in their policies and procedures, which emphasize accommodating individual needs and preferences.
Failure to Notify Physician of Resident's Refusal of RNA Program
Penalty
Summary
The facility failed to notify the resident's physician for a change in condition for a resident who repeatedly refused participation in the Restorative Nursing Aide (RNA) program. The resident, who had severe cognitive impairments and was dependent on staff for various activities of daily living, was at risk for contracture development due to hemiplegia and hemiparesis following a cerebral infarction. Despite the resident's refusals to participate in RNA treatments, which were documented on multiple occasions, the facility did not assess, address, or report these refusals to the physician as required by their policy. The resident's care plan included interventions to prevent further contractures, such as performing passive range of motion (PROM) exercises and applying a left resting hand splint. However, the resident frequently refused these treatments, and there was no documentation of a change in condition assessment or notification to the physician. Observations revealed that the resident's left hand was in a fisted position, and a contracture-related pressure injury developed on the left middle finger, which was assessed as a Stage 4 wound. Interviews with facility staff, including the Wound Treatment Nurse, Occupational Therapist, and Registered Nurse Supervisor, confirmed that the refusals were not communicated to the physician or adequately documented. The facility's policy required notification of the physician after two consecutive refusals of treatment, but this was not followed. The lack of communication and documentation led to a delay in assessment and intervention, contributing to the resident's worsening condition.
Failure to Develop Care Plan for Alleged Abuse
Penalty
Summary
The facility failed to develop an individualized person-centered care plan for a resident, identified as Resident 60, following an allegation of verbal harassment by the Director of Nursing (DON). Resident 60, who was readmitted to the facility with multiple diagnoses including end-stage renal disease, hypertension, hemiplegia, and hemiparesis, reported feeling verbally harassed by the DON during an interaction on February 3, 2025. Despite the resident's cognitive intactness and the potential for emotional distress, no care plan was initiated to address the alleged abuse. The incident was first brought to the attention of the facility's Administrator on February 10, 2025, during an interview with the resident. The resident described the DON as aggressive and intimidating, which made him upset. Although the facility conducted an investigation and reported the incident to the surveyor, they were unable to substantiate the allegation of abuse. However, the lack of a care plan for the alleged abuse was confirmed during a review of the resident's care plans with the MDS Nurse. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, including measurable objectives and timetables to meet their physical, psychosocial, and functional needs. The MDS Nurse and the DON both acknowledged that a care plan should have been initiated for the alleged abuse to ensure the resident's needs were met and to monitor for any emotional symptoms. The absence of such a care plan indicated a failure to adhere to the facility's policy and potentially delayed the delivery of appropriate care for Resident 60.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to accurately assess a resident's fall risk, which led to a deficiency in providing necessary care and services to prevent accidents and falls. The resident, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, and a history of stroke, was initially assessed as low risk for falls. However, this assessment was incorrect as it did not account for the resident's use of antihypertensive and narcotic medications, nor the presence of a cerebrovascular accident diagnosis, which should have classified the resident as moderate risk for falls. The resident's care plan, revised shortly after admission, correctly identified the resident as high risk for falls due to factors such as confusion, deconditioning, and balance problems. Despite this, the initial fall risk assessment failed to reflect these risks accurately. Observations confirmed that the resident was provided with interventions such as a low bed and floor mats, but the inaccurate assessment could have led to inadequate preventive measures being implemented. Interviews with facility staff, including an LVN and the MDS Nurse, revealed acknowledgment of the incorrect fall risk assessment. The MDS Nurse confirmed that the assessment did not accurately reflect the resident's medication use and medical history, which would have increased the fall risk score. The Director of Nursing also recognized the importance of accurate fall risk assessments in developing effective care plans and preventing falls, highlighting the potential for falls if assessments are not conducted correctly.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility failed to provide necessary colostomy care for a resident, identified as Resident 4, who was readmitted with a colostomy but did not have appropriate orders for colostomy care until several months later. The resident's medical history included quadriplegia, an ulcer, obesity, type 2 diabetes, and a colostomy. Upon review, it was found that there were no documented orders for cleaning, applying skin prep, and changing the colostomy bag until the survey began. This lack of documentation and orders could lead to potential complications such as infection, skin irritation, and obstruction. Observations and interviews revealed that the colostomy bag was not dated or timed, and there was no documentation of colostomy care in the resident's electronic health record. The Infection Preventionist and a Licensed Vocational Nurse confirmed the absence of documentation and were unaware of the facility's policy regarding colostomy care documentation. The Director of Nursing acknowledged that without documentation, it could not be confirmed that the care was provided, which could lead to infection control issues. The facility's policy required documentation of colostomy care, including the date, time, and any signs of infection or skin issues.
Failure to Provide Nutritional Supplements and Monitor Weight
Penalty
Summary
The facility failed to perform weekly weights and provide a Magic Cup supplement twice a day with meals for a resident who had a history of significant weight loss. The resident was admitted with multiple diagnoses, including schizoaffective disorder, major depressive disorder, and anemia, and was identified as having a nutritional risk due to these conditions. The resident experienced a weight loss of 10.2 lbs. or 8.9% in one month and 13.2 lbs. or 11.3% in three months, indicating severe weight loss. The physician orders for the resident included receiving a Magic Cup supplement twice a day with meals and weekly weights for four weeks. However, the resident's meal tray did not include the Magic Cup supplement, and the dietary supervisor confirmed that the meal tray card did not indicate the need for the supplement. Additionally, the resident's weight was not documented weekly as required, with missing records for January 2025. The lack of documentation and failure to provide the supplement were confirmed by various staff members, including the Licensed Vocational Nurse, Registered Dietitian, and Director of Nursing. The facility's policy on weight assessment and intervention emphasized the importance of monitoring resident weights for undesirable weight loss and implementing interventions based on various factors. Despite this policy, the resident did not receive the necessary care to address her weight loss, as evidenced by the failure to perform weekly weights and provide the prescribed Magic Cup supplement. This deficiency had the potential to result in further weight loss for the resident.
Lack of Restorative Nursing Assistant Certification
Penalty
Summary
The facility failed to provide a Restorative Nursing Assistant (RNA) certificate for one of the two sampled Restorative Nursing Assistants, identified as RNA 1. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), who had been on the job for only seven days and was in the process of organizing the facility's files. RNA 1's employee record did not contain a copy of the RNA certificate, and the DSD stated that RNA 1 was attempting to locate his certificate since the facility did not have it on file. Further interviews with the Registered Nurse Consultant 2 (RNC 2), the Director of Nursing (DON), and the facility Administrator (ADM) confirmed that without the RNA certificate, the facility could not verify RNA 1's competency to perform restorative nursing aid care. The facility's policy and procedure on the competency of nursing staff required that nursing staff meet specific competency requirements for their respective licenses and certifications. The absence of RNA 1's certificate meant the facility could not demonstrate that RNA 1 had the necessary education or skills to provide restorative care, potentially placing residents at risk.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 22.22% due to six medication errors out of 27 opportunities. These errors affected three residents during medication administration. The errors included the omitted or late administration of vitamin D to one resident and artificial tears to another. Additionally, there were attempts to administer a mixture of crushed medications without proper verification of their compatibility, which could have led to adverse effects. One resident, diagnosed with dementia and schizoaffective disorder, did not receive their prescribed vitamin D supplement during the 9:00 AM medication pass. The Licensed Vocational Nurse (LVN) responsible for the administration failed to remove discontinued medications from the cart, leading to confusion and the omission of the vitamin D. Another resident, with a history of hypertension and dry eye syndrome, did not receive their prescribed artificial tears, as the LVN did not include them in the medication pass. A third resident, who lacked the capacity to make decisions, was nearly administered a mixture of crushed medications, including escitalopram, hydrochlorothiazide, losartan, and aspirin, without verifying their compatibility. The LVN involved did not consult with other staff or reference materials to ensure the safety of the medication combination. This oversight was identified and halted by a surveyor before administration, preventing potential medical complications.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage medications in two inspected medication carts, leading to potential risks for residents. In one instance, 36 doses of discontinued divalproex 125 mg tablets were not removed from Medication Cart 2, which resulted in a Licensed Vocational Nurse (LVN 1) administering both the discontinued tablets and the sprinkle capsules of divalproex to Resident 191. This oversight occurred despite the order for the tablets being discontinued the previous day. LVN 1 acknowledged the risk of administering discontinued medications, which could lead to adverse effects such as drowsiness or dizziness for the resident. Additionally, Medication Cart 1 contained dronabinol 10 mg capsules stored at room temperature instead of the required refrigeration, as per the manufacturer's instructions. LVN 3 was unaware of the storage requirements, which could affect the medication's efficacy in stimulating appetite. The facility's policy on medication storage, which mandates the removal of discontinued drugs and proper storage conditions, was not adhered to, increasing the risk of negative health outcomes for residents.
Failure to Follow Fortified Diet Guidelines
Penalty
Summary
The facility failed to ensure that fortified diet guidelines were followed during lunch preparation and tray line observation. On the specified date, Dietary Aide (DA1) did not communicate the fortified diet orders written on the meal tickets during the lunch service. As a result, Cook1, who was responsible for serving the food, did not add the necessary additional food items per the fortified menu. This oversight affected seven residents who required a fortified diet to increase their caloric intake. During interviews, Cook1 and DA1 acknowledged the failure to follow the fortified diet protocol. Cook1 explained that melted margarine should have been added to the meals of residents on fortified diets, but this was not done because DA1 did not announce the fortified diet orders. The Registered Dietitian confirmed that fortified diets are essential for residents experiencing weight loss, as they provide additional calories and protein. The dietary supervisor emphasized the importance of following the menu, and a review of the facility's policy highlighted the procedure for fortifying food to meet residents' nutritional needs.
Failure to Provide Correct Food Texture for Residents on Modified Diets
Penalty
Summary
The facility failed to provide food in the correct texture for residents on modified diets, leading to potential risks for those with chewing and swallowing difficulties. During a lunch service observation, it was noted that 15 residents on a pureed diet received corn salad that was thin and soupy instead of having a smooth, pudding-like consistency. The dietary aide, instructed by a cook, blended the corn salad with water, resulting in a liquid mixture with pulp, contrary to the facility's policy for pureed diets. The Registered Dietitian confirmed the inappropriate texture, which could pose a problem for residents requiring pureed diets and thickened liquids. Additionally, two residents on a finely chopped diet and three residents on a ground meat diet received flaked fish instead of the required textures. The cook admitted to only preparing regular and flaked fish, without chopping or grinding it as per the residents' diet orders. The Registered Dietitian acknowledged the absence of guidance for these diet textures in the facility's menu and serving guide, indicating a need for reevaluation and clarification of diet orders. This oversight could lead to issues with chewing or swallowing for residents on these modified diets.
Deficient Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices in the kitchen, as observed during a survey. Several food items, including turkey and cheese sandwiches and a plate of salad with chopped ham, were found in the reach-in refrigerator without any dates. Additionally, a tuna salad sandwich and another turkey and cheese sandwich were stored with dates exceeding the recommended storage periods. A bag of deli meat in the reach-in freezer was also found without a label or date, and ice crystals were observed on the meat, indicating improper storage. Interviews with the cook and dietary supervisor revealed a lack of knowledge about when the sandwiches and salads were prepared, as they were not dated. The dietary supervisor confirmed that all prepared salads and sandwiches should be dated on the day they are made and discarded if not used within the same or next day. The registered dietitian stated that tuna salad should be kept for about three days per storage guidelines, but was unaware of when the tuna salad for the sandwich was prepared. The facility's policies on labeling, dating, and storing food were not followed, leading to potential harmful bacteria growth and decreased food quality for 83 out of 84 residents.
Lack of Policy for Bioethics Committee in LTC Facility
Penalty
Summary
The facility failed to establish a policy and procedure for their Bioethics Committee, which is responsible for making medical decisions for residents who lack the capacity to do so themselves. This deficiency affected 13 residents, including Resident 19, who were represented by the Bioethics Committee. The absence of a formal policy placed these residents at risk for ineffective care and unmet needs. Resident 19 was admitted with multiple diagnoses, including metabolic encephalopathy, schizophrenia, dementia, bipolar disorder, and hemiplegia. The Bioethics Committee, consisting of the Medical Director, Administrator, Director of Nursing, and Social Worker, assumed the role of Resident 19's responsible party due to the resident's inability to make informed decisions and lack of family support. However, there was no documentation regarding the application for a state-appointed conservator or guardian for Resident 19. Interviews with facility staff revealed that the Bioethics Committee operated without specific guidance or a formal policy. The Administrator provided a policy titled 'Resident Representative,' which did not address the Bioethics Committee's role. The Social Services Director confirmed that 13 residents were under the committee's representation, and the process for applying for conservatorship lacked a specific timeline. The facility's failure to have a structured policy for the Bioethics Committee led to a deficiency in providing effective and efficient care for residents unable to make their own medical decisions.
Inaccurate Documentation of Vital Signs Across Shifts
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for seven residents, as evidenced by identical vital signs recorded by the same LVN across multiple shifts. This issue was identified for Residents 77, 53, 341, 32, 62, 21, and 19, with the same vital signs documented on consecutive days for both the 3:00 PM - 11:30 PM and 11:00 PM - 7:30 AM shifts. The Director of Nursing (DON) acknowledged the identical records but did not classify them as falsification, despite the lack of variation in the documented vital signs. Resident 19, for example, was admitted with multiple diagnoses, including metabolic encephalopathy, schizophrenia, dementia, bipolar disorder, and hemiplegia. The review of the Medication Administration Record (MAR) for Resident 53 showed consistent vital signs across shifts and days, which were identical to those recorded for other residents. This pattern was repeated for Residents 341 and 32, as well as for Residents 62, 21, and 19, indicating a systemic issue with the documentation process. During interviews, the DON stated that daily documentation by the LVN was required but not necessarily for each shift, and no specific policy was provided to support this claim. The facility's policy on routine resident checks contradicted the DON's statement, requiring documentation for each shift. LVN 4, who worked the night shift during the period in question, claimed the documented vital signs were accurate but could not explain the identical records across shifts. This discrepancy highlights a failure in maintaining accurate and reliable medical records, which is crucial for ensuring adequate resident care.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in an incident where one resident, diagnosed with schizophrenia and mood disorder, became physically aggressive towards another resident. The aggressive resident, who had a history of ineffective coping skills and poor impulse control, approached the second resident while they were resting in bed, leading to a physical altercation. This resulted in the second resident sustaining a skin tear on the left ear. The aggressive resident had been admitted with diagnoses including anxiety and depressive episodes, and was noted to have no cognitive impairments according to their Minimum Data Set (MDS). Despite this, the resident had a known history of aggression, particularly when things were not done according to their preferences, such as volume control on TVs and adherence to bathing schedules. Staff interviews revealed that the resident's aggressive behavior was a known issue, with several instances of aggression reported to the charge nurse prior to the incident. The second resident, who also had a diagnosis of schizophrenia and mood disorders, was noted to have no cognitive impairments or history of aggressive behavior. The facility's staff, including the Director of Nursing, were aware of the aggressive resident's triggers and acknowledged that the facility might not be equipped to meet the resident's needs. The facility's policy on abuse and neglect defines abuse as the willful infliction of injury or intimidation, which was not adequately prevented in this case.
Failure to Notify Resident's Representative of Room Change
Penalty
Summary
The facility failed to notify a resident's representative before moving the resident from one room to another, which is a violation of the resident's rights. The resident, who had severe cognitive impairments and required substantial assistance with daily activities, was moved from Room A to Room B without prior notification to their responsible party (RP). The facility's policy requires that residents and their families be informed of room changes, but this was not adhered to in this case. The social service assistant attempted to contact the RP but was unable to leave a message and did not document the attempt in the progress notes. The facility's policies on room transfers and changes in a resident's condition or status clearly state that the resident's representative should be notified, but this procedure was not followed. This oversight resulted in the resident and their RP not being informed of the room change or the reasons behind it.
Neglect of Cognitively Impaired Resident in Hallway
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident being left unattended and exposed in a hallway for approximately 59 minutes. The resident, who was cognitively impaired and diagnosed with dementia, was observed crawling and lying on the floor with his body partially uncovered. Despite being within eyesight of multiple staff members, including CNAs and LVNs, the resident did not receive assistance, comfort, or safety measures during this time. The resident's care plan, initiated on the same day, highlighted the need for constant supervision due to the resident's behavior of crawling out of bed. However, the staff failed to implement these interventions, as evidenced by surveillance footage showing the resident's prolonged exposure and lack of assistance. Interviews with staff members revealed that they were aware of the resident's behavior but did not take appropriate action to address it, citing reasons such as being assigned to other residents or not being directly responsible for the resident. The facility's policy and procedure on abuse and neglect emphasized the importance of addressing residents' needs to prevent neglect. However, the staff's inaction and failure to preserve the resident's dignity were acknowledged by the facility's administrator and DON. The surveillance footage, which was later deleted, captured multiple instances where staff members ignored the resident's plight, further highlighting the deficiency in care provided to the resident.
Failure to Conduct PT Evaluations After Resident Falls
Penalty
Summary
The facility failed to ensure that residents who experienced falls were assessed by a physical therapist (PT) to identify causative factors and implement safety interventions. Resident 1, admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, had an unwitnessed fall on 8/12/24, resulting in a bump on the forehead. Despite the fall, no PT evaluation was conducted to assess the resident's physical function and safety awareness. Similarly, Resident 2, who had diagnoses including right hip osteoarthritis and lack of coordination, experienced an unwitnessed fall on 8/14/24, resulting in a laceration on the cheek and a partially detached thumbnail. The facility did not perform a PT evaluation following this incident. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed the absence of PT evaluations for both residents after their falls, contrary to the facility's policy requiring post-fall evaluations to enhance safety awareness and prevent further incidents.
Failure to Monitor and Manage Resident's Schizophrenia and Wandering
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizophrenia and a history of wandering. The resident was not monitored for schizophrenic behavior each shift as per the physician's order, and the care plan interventions were not evaluated for effectiveness or updated based on the resident's behavior and needs. Additionally, the facility did not develop an appropriate care plan for the resident's wandering behavior, nor did they provide adequate supervision or anticipate the resident's needs to prevent agitation. As a result of these deficiencies, the resident wandered the facility and entered another resident's room, leading to a physical altercation where the resident struck the other resident in the face, causing a bleeding lip. The incident highlighted the lack of effective interventions and monitoring for the resident's wandering and aggressive behaviors, which were not addressed in the care plan. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed that the care plans lacked individualized, person-centered interventions and that staff documentation inaccurately reflected the resident's condition. The facility's policies on wandering, elopement, and abuse prevention were not effectively implemented, contributing to the incident and the potential for harm to other residents.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with diagnoses of anxiety disorder and schizophrenia, did not have a complete baseline care plan within the specified timeframe. The Director of Nursing (DON) acknowledged that only the dietary section of the baseline care plan was completed, and the rest was not finished. The DON was unaware of the specific timeframe required for completing the baseline care plan. The Minimum Data Set (MDS) for the resident indicated moderately impaired cognitive skills and a need for partial/moderate assistance with daily activities such as toileting hygiene, dressing, bathing, and walking. The MDS Coordinator confirmed that the baseline care plan was not completed upon admission, which could lead to an inability to meet the resident's immediate care needs. The facility's policy, revised in December 2016, mandates that a baseline care plan be developed within 48 hours of admission to address the resident's immediate needs, including initial goals based on admission orders and other relevant services.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Healthcare Center | 0.1 mi | ★★★★★ | 4 | 0 |
| Alden Terrace Convalescent Hospital | 1.8 mi | ★★★★★ | 14 | 0 |
| Vernon Healthcare Center | 1.8 mi | ★★★★★ | 32 | 0 |
| Alvarado Care Center | 1.8 mi | ★★★★★ | 29 | 0 |
| Olympia Convalescent Hospital | 1.9 mi | ★★★★★ | 1 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.