Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley View Post Acute during CMS and state inspections, most recent first.
Two residents had inaccurate MDS coding. One resident’s MDS failed to record a fall that was documented in the chart, and another resident’s initial MDS incorrectly showed insulin injections despite no insulin order and only a weekly Mounjaro injection. The MDSC and DON stated the MDS must match the medical record and is used for CMS reporting and care planning.
A facility failed to develop individualized care plans for three residents with identified needs. One resident had an AICD documented in hospital records, another was a smoker requiring supervision with no smoking safety care plan, and a third had a documented fall with no fall care plan. Records showed significant cognitive and functional impairment in all three residents, and the DON and MDSC confirmed the missing care plans during review.
A resident with severely impaired cognition, no decision-making capacity, and a smoking history had a pack of cigarettes stored on the wheelchair at bedside, despite being assessed as needing staff supervision for smoking. In a separate issue, water was observed on the hallway floor and in resident rooms after shower transport, and CNA and MS interviews confirmed the water had been present long enough to create a slip hazard.
Unlabeled oxygen tubing for two residents. The facility failed to follow its respiratory infection prevention policy when two residents receiving continuous O2 had nasal cannula tubing that was not dated after changes. One resident had lung cancer and respiratory failure, and the other had metabolic encephalopathy, pleural effusion, and severely impaired cognition. Staff stated tubing should be labeled with the last change date to track weekly replacement and prevent infection.
Expired mustard bottles were found in Kitchen 1's dry storage room, with seven 13-ounce bottles still present despite a use-by date that had passed. The DS stated the bottles should have been discarded, and the DON stated expired food could be rotten and potentially cause food poisoning if consumed by residents.
Infection Control Failure in Kitchen Dry Storage: Unlabeled resealable bags and a wooden caddy containing staff-use plastic spoons, cup lids, and condiment packets were found in Kitchen 1's dry food storage room near residents' food items. The DS stated the items belonged to nursing staff, were not supposed to be in the dry storage room, and could be accidentally given to a resident. The DON stated these staff-use items should not be kept in the dry food storage room, and the facility's IPCP policy called for maintaining a safe, sanitary environment and preventing transmission of infection.
Pest control program failed when gnats were observed in a resident's room and in care areas, including the nurses' station and conference room. A resident with Parkinson's Disease reported the insects had been present for weeks and were annoying, while an LVN found no food or fruit in the room to explain them. The MS said the facility had a pest control program but was unaware of the gnats until they were reported, and the DON stated insects in resident areas were an infection risk and not homelike.
Call Light Not Kept Within Reach: A resident with morbid obesity, muscle wasting and atrophy, COPD, and an above-the-knee L leg amputation had a care plan intervention to keep the call light within reach, but surveyors observed the call light on the floor behind the bed while the resident was in bed and needing nursing assistance. The resident stated the call light was often not within reach and that help was sought by watching the hallway and yelling to staff passing by; CNA and DON interviews confirmed the call light should be available for resident assistance.
Late Initial MDS Assessment: The facility failed to complete and submit a new resident’s initial MDS within the required timeframe. The resident had diagnoses including type 2 DM, non-Hodgkin lymphoma, and anemia, and was documented as cognitively intact with maximal assistance needed for toileting hygiene and bathing. The MDSC stated the initial MDS was completed, locked, and submitted late, and the DON stated MDS assessments are used to identify resident conditions and guide care.
A resident with ESRD and dependence on renal dialysis had active orders for HD four times per week and a 1,000 ml fluid restriction, but the care plan still listed an older HD schedule and different fluid allocations for Nursing and Dietary. LVN and DON interviews confirmed the care plan had not been updated to match the current orders, despite the resident’s changing HD schedule and fluid restriction needs.
Failure to apply ordered bilateral PRAFO braces: A resident with bilateral ankle contractures, severe cognitive impairment, and impaired ROM was observed with only one PRAFO brace in place while the other was lying on the bed. The care plan and active order required bilateral PRAFO braces to be applied for several hours on scheduled days, and staff confirmed both braces should have been on to help prevent worsening foot drop and ankle contracture.
A resident with HTN, DM, and moderately impaired cognition had an opened bottle of Italian dressing brought by family left at the bedside without a name or date label. Staff observed the dressing remained out of proper storage, while CNA and IPN interviews confirmed outside food should be labeled and refrigerated per facility policy. The DON also confirmed the bottle lacked the required labels and should have been stored in the refrigerator.
Failure to Report Injury of Unknown Source: A resident with severe cognitive impairment, hemiparesis, and extensive ADL dependence developed unexplained facial bruising and discoloration, along with a scratch and forearm bruising. Staff reported seeing the injuries but did not witness how they occurred, and the DON stated the event was not reported to CDPH because the facility later attributed it to the resident hitting a bedrail.
A resident with cerebral infarction, left-sided hemiparesis, and severely impaired cognition had no care plan documented for a fall that resulted in abrasions to the midback and no care plan for repetitive behavior of placing an arm through the bed rail. The DON stated the behavior should have been care planned, and the facility policy required comprehensive person-centered care plans with measurable objectives, time frames, and services to support the resident's highest practicable well-being.
A resident with cerebral infarction, left-sided hemiparesis, severe cognitive impairment, and dependence for multiple ADLs was found sitting on the floor with abrasions to the midback, but no post-fall fall risk assessment or rehab screen was documented. The record also lacked a COC entry when the resident’s arm became stuck in the bed rail and redness was noted on the forearm; CNA and LVN interviews confirmed the resident frequently placed the arm in the rail gaps and needed staff assistance to remove it.
A resident with multiple chronic conditions and moderate cognitive impairment was transferred to a GACH and then to an LTACH, with documentation from the LTACH physician that the resident had improved and stabilized. When the LTACH requested the resident’s readmission, facility staff, including the administrator and marketing staff, declined, citing lack of a Candida auris isolation bed, despite census records and staff interviews confirming that several semi-private rooms had available female beds and could have been rearranged to accommodate the resident. Another resident was later admitted to the same room that could have been used, and an IP confirmed there were no current C. auris isolation residents and that an empty room could have been designated for isolation. The facility’s own bed-hold policy required allowing returning residents to their previous room if available or to the first available bed when they still required facility services and remained eligible for Medicare or Medicaid.
Two residents with significant cognitive and physical impairments, both at high risk for falls, were found without their call lights within reach as required by facility policy. In both cases, staff confirmed the call lights were not accessible, and the residents were unable to independently request assistance, despite care plans and assessments indicating the need for this safety measure.
The facility failed to accurately document the hearing impairment of a resident and the discharge status of another on the MDS. One resident's significant hearing loss was not reflected in the assessment despite clear evidence from staff and the resident, resulting in a delay in evaluation for hearing aids. Another resident's discharge was incorrectly coded as a transfer to a hospital instead of a SNF, despite documentation showing the correct destination. These errors resulted in inaccurate assessments and had the potential to negatively impact resident care.
The facility did not monitor or document fluid intake for a resident on fluid restriction and failed to record weekly weights for another resident who experienced significant weight gain, despite physician and dietitian recommendations. These actions were not in accordance with facility policies for nutritional management and care planning.
Two residents with gastrostomy tubes did not receive site care as ordered by their physicians and care plans, including cleaning, covering with a drain sponge, and securing with retention tape. Observations and staff interviews confirmed that the GT sites were not properly dressed or secured, contrary to facility policy and physician orders.
Two residents receiving oxygen therapy were not provided respiratory care in accordance with facility policy and professional standards. In one case, nasal cannula tubing was observed touching the floor while in use, and in another, the tubing was left on a suction bottle with visible secretions instead of being stored in a plastic bag when not in use. Staff interviews confirmed these practices did not meet infection control protocols, despite active physician orders for continuous oxygen therapy.
Surveyors identified deficiencies in food storage and sanitation, including an open bag of tortillas left in dry storage and the presence of pink and dark substances inside the kitchen ice machine. Staff interviews and facility policies confirmed these practices did not meet required standards for food safety and sanitation.
The facility did not follow its antibiotic stewardship policy for three residents who were prescribed antibiotics for various infections, including abscess, MSSA, pseudomonas bacteremia, and pneumonia. Required McGeer Criteria forms were not completed to justify antibiotic use, as confirmed by the IPN and DON, resulting in antibiotics being administered without documented screening for appropriateness.
A resident with multiple chronic conditions and moderately impaired cognition was readmitted without completion of required POLST and Advance Directive Acknowledgement forms. Interviews with the ADON and DON confirmed that these documents were not updated as per facility policy, which mandates their completion with every admission and re-admission to ensure care preferences are current.
A resident who spoke only Cantonese and required an interpreter did not have a communication board or device at bedside to communicate with staff, despite being alert and needing assistance. Staff and the DON confirmed that such aids should have been provided, and facility policy required visual communication aids for residents with language barriers.
A resident with chronic vaginal yeast infection and multiple comorbidities experienced persistent vaginal and buttock itching, redness, and discomfort. Despite repeated complaints and documented symptoms, staff did not consistently assess or report the condition to the physician, and a gynecological consult was not scheduled as ordered. The resident's symptoms remained unrelieved, and staff communication lapses contributed to the deficiency.
A resident with severe cognitive impairment and multiple medical conditions experienced ongoing difficulty hearing, requiring staff to speak loudly and for the resident to read lips. Despite the resident's expressed need and staff observations, the facility did not schedule an audiology consult or provide a hearing aid, contrary to facility policy requiring assistance with obtaining assistive devices.
A resident with severe cognitive impairment and a Stage 4 sacro-coccyx pressure ulcer was not repositioned every two hours as required by care plans and physician orders. Despite staff awareness of the protocol and the use of a low air loss mattress, the resident was observed in the same position outside of the scheduled turning times, increasing the risk of further skin breakdown.
A resident with severe cognitive impairment, hemiplegia, and high fall risk was not provided with the required two-person assistance during ADLs, resulting in a fall when only one CNA assisted with turning and changing. Additionally, no individualized care plan addressing the resident's fall risk was developed prior to the incident, despite facility policy and assessment findings.
A resident with an indwelling Foley catheter was found with the catheter tubing unsecured and the securement device broken, contrary to facility policy requiring the tubing to be anchored to the thigh. Both an LVN and the DON confirmed that the tubing should have been secured to prevent trauma, but this was not done, resulting in a deficiency related to catheter care.
A resident with severe cognitive impairment and physical limitations was placed in bed with bilateral side rails without documented attempts to use alternative interventions. Staff confirmed that no alternatives were tried or evaluated prior to installing the side rails, contrary to facility policy, placing the resident at risk for entrapment and injury.
A resident's binding arbitration agreement did not include provisions for selecting a venue convenient to both the facility and the resident or their representative, as required by facility policy. The outdated agreement form used did not specify how a mutually convenient location would be determined, despite the facility's policy stating that both parties should agree on the venue.
A resident with MRSA-positive wounds was not provided with required Enhanced Standard Precautions, including missing signage and PPE cart outside the room. Staff did not consistently wear gowns and gloves during wound care, and interviews confirmed that infection control protocols were not followed according to facility policy.
Sixteen resident rooms did not meet the minimum square footage requirement of 80 square feet per resident for multiple occupancy rooms. Despite this, residents and staff reported no issues with space for mobility or care, and observations confirmed adequate room for equipment and movement.
The facility failed to report an allegation of resident-to-resident abuse to the appropriate authorities within the required two-hour timeframe. The incident involved one resident allegedly coming into contact with another resident's arm in the dining hall. Staff interviews confirmed the facility's policy required immediate reporting to ensure resident safety and timely investigation, but the report was delayed.
The facility failed to maintain milk at the appropriate temperature, with two out of three sampled glasses exceeding 41 degrees Fahrenheit. Dietary staff acknowledged the risk of foodborne illness from milk stored at 56 degrees Fahrenheit, which is outside the safe range specified in the facility's policy. Discrepancies in understanding the correct temperature range were noted among staff.
The facility did not provide required one-to-one activities for two residents with severe cognitive impairments and physical limitations, as outlined in their care plans. Observations showed a lack of engagement, and the Activities Assistant confirmed these residents were not on the activity schedule, despite facility policy. The MDS assessments for both residents were incomplete, missing crucial information on their activity preferences.
The facility failed to follow physician's orders for continuous oxygen administration for two residents, leading to potential health risks. One resident with chronic respiratory failure was found without their nasal cannula in place, and another resident with hemiplegia and atelectasis had their nasal cannula lying on the bedsheets instead of being used. LVNs confirmed the need for continuous oxygen and the potential for respiratory distress if not administered.
The facility failed to post accurate staffing information, including the hours of an MDS nurse not directly responsible for resident care, and omitted the facility's name. The Director of Staff Development misunderstood the role of the MDS nurse, leading to the posting of projected rather than actual hours worked.
The facility failed to maintain proper sanitization levels in the kitchen, with quaternary ammonium sanitizer solution and dishwasher chlorine levels below recommended concentrations. This was observed during an inspection, where the sanitizer solution was 0 ppm and the dishwasher chlorine was 10 ppm, both below required levels for effective cleaning. The facility's policies required regular testing and maintenance of these concentrations to prevent foodborne illnesses.
The facility failed to implement infection control measures for two residents. A resident's nasal cannula was found on the floor and improperly handled by an LVN, while another resident requiring Enhanced Barrier Precautions did not receive proper PPE use during a linen change by a CNA. These actions were contrary to the facility's infection prevention policies.
A resident with hemiplegia and aphasia developed a new skin condition that was not reported to the physician, violating the facility's skin condition policy. Despite staff observations and reports of itching, communication breakdowns led to a lack of documentation and delayed medical assessment. The resident was eventually diagnosed with contact dermatitis, underscoring the facility's failure to ensure timely intervention.
A facility failed to notify the Ombudsman of a resident's discharge to an acute care hospital, as required by regulation. The resident, with diagnoses including metabolic encephalopathy and acute metabolic acidosis, was transferred twice without documented notification to the Ombudsman. Quality Assurance Nurse 2 acknowledged the lack of documentation, which is part of the facility's procedure to fax the Notice of Proposed Transfer/Discharge and retain confirmation in the resident's record.
A facility failed to reposition a high-risk resident every two hours as required by their care plan, leading to potential risk for skin breakdown. The resident, who had limited mobility and a history of pressure injuries, was not turned on multiple occasions, as confirmed by an LVN and the Interim DON. The facility's policy mandates repositioning every two hours, which was not adhered to.
A resident with an unstageable pressure ulcer on the left heel did not receive daily wound care treatment as ordered. The treatment was delayed, with missed treatments on two consecutive days due to an error in entering the physician's order. The Wound Care Nurse and Interim Director of Nursing confirmed the oversight, which could potentially worsen the resident's condition.
A resident with dementia and obstructive uropathy, using an indwelling catheter, was not properly monitored for UTI symptoms. Despite signs of infection, such as cloudy urine with sediments, staff failed to notify the physician promptly, as required by the care plan and facility policy. This oversight was discovered during a survey, highlighting a lapse in communication and monitoring by the nursing staff.
A resident with age-related osteoporosis and muscle wasting experienced ongoing knee pain due to the facility's failure to reassess pain after administering diclofenac gel. The resident reported an 8/10 pain level, but the LVN did not follow up as required by the facility's pain management policy.
A resident with dementia and diabetes was placed in a bed with quarter-length bed rails without documented attempts of alternative measures. The facility's policy required alternatives like roll guards or foam bumpers to be tried first, but this was not done. The IDON acknowledged the risk of injury or death due to entrapment, confirming the deficiency.
A facility failed to attempt a Gradual Dose Reduction (GDR) for a resident on Quetiapine Fumarate, despite the resident having only one episode of striking out in 22 days. The resident's daily dose was increased without adequate indication, and the medical record lacked documentation of a GDR attempt, contrary to facility policy.
The facility failed to meet the requirement of 80 square feet per resident in 16 rooms, affecting the care provided. Observations showed sufficient space for movement and storage, but the Operations Manager confirmed the deficiency and submitted a waiver request for the room size per bed.
Inaccurate MDS Coding for Fall History and Insulin Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected resident assessments for two sampled residents. For one resident, the MDS dated [DATE] did not code a fall that occurred on 5/28/2026, even though the Change in Condition Evaluation documented that the resident had a fall in the afternoon. The resident’s record also showed severely impaired cognition and dependence on staff for oral hygiene, toileting hygiene, showering/bathing, and bed-to-chair transfers. During review, the MDS Coordinator stated the assessment was not accurate and should have coded that the resident had a fall since admission. For the second resident, the initial MDS dated 4/13/2026 incorrectly indicated that insulin injections had been received for one day since admission. The resident’s record showed diagnoses including type 2 diabetes, non-Hodgkin lymphoma, and anemia, and the resident was cognitively intact with capacity to understand and make decisions. The physician order summary showed no order for insulin injections; instead, the resident had an order for Mounjaro 2.5 mg by injection every Wednesday. The MDS Coordinator stated Mounjaro is not insulin and that the section of the MDS was incorrect because it should not have indicated insulin injections were received. The MDS Coordinator stated that MDS assessments must be accurate, reflect resident records, and are signed to attest to accuracy before being transmitted to CMS. The DON also stated that accurate MDS assessments are important because they are used to identify resident conditions and guide care planning. The facility policy stated that information in the MDS assessments will consistently reflect progress notes, plans of care, and resident observations/interviews.
Missing Person-Centered Care Plans for AICD, Smoking Safety, and Fall Event
Penalty
Summary
The facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans for three sampled residents. Resident 10 was admitted with diagnoses including diabetes mellitus and atrial fibrillation, and records from the acute care hospital indicated the resident had an AICD. The resident’s H&P stated the resident had the capacity to understand and make decisions, while the MDS showed moderately impaired cognition and extensive assistance needs with eating, oral hygiene, personal hygiene, transferring, toileting hygiene, showering, and bathing. Review of the entire care plan showed no care plan addressing the AICD. Resident 75 was admitted with diagnoses including epilepsy and muscle wasting and atrophy. The H&P documented a history of tobacco use and that the resident did not have the capacity to understand and make decisions, while the MDS showed severely impaired cognition and varying levels of assistance needed with eating, oral hygiene, personal hygiene, toileting hygiene, showering/bathing, and bed-to-chair transferring. A smoking observation/assessment indicated the resident smoked cigarettes and required staff supervision, and the resident was observed smoking on the facility smoking patio under the Activity Director’s supervision. Review of the care plans showed no care plan developed to address smoking safety. Resident 86 was admitted with diagnoses including cerebral infarction, dementia, and muscle wasting and atrophy. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed severely impaired cognition with dependence on staff for oral hygiene, toileting hygiene, showering/bathing, and bed-to-chair transferring. A change in condition evaluation documented that the resident had a fall in the afternoon of 5/28/2026, but review of the entire care plan showed no care plan addressing the fall. The facility policy stated care plans should be comprehensive and person-centered and developed within seven days of the required MDS assessment and no more than 21 days after admission.
Unsafe Smoking Storage and Wet Floors
Penalty
Summary
The facility failed to maintain a safe environment for Resident 75 when a pack of cigarettes was found on the resident’s wheelchair at bedside. Resident 75 was admitted with diagnoses including epilepsy and muscle wasting and atrophy, had no capacity to understand and make decisions, and had severely impaired cognition. The resident’s assessment indicated a history of tobacco use and that the resident smoked cigarettes and required staff supervision. During observation, the resident was awake and sitting in a wheelchair with a pack of cigarettes next to the right hip, and cigarettes were stored inside the pack. The resident stated the cigarettes had been brought by the brother. The DON stated cigarettes should be stored with Activity staff, that residents should not keep cigarettes in the room because of fire and injury risk, and that Resident 75 could light a cigarette without staff supervision. The AD stated the activity department stored and locked residents’ cigarettes and lighters in the activity cabinet for safety and supervision, and that if a resident kept cigarettes in possession, the resident could smoke in the room and accidentally cause fire. The facility also failed to keep the hallway and resident rooms free from water after showering residents. Water was observed on the floor in the hallway and in two resident rooms, including one room where CNA 2 stated the water came from transporting a resident from the shower room to the room. CNA 2 stated the water had been reported to the Maintenance Supervisor about 15 minutes earlier and said it was dangerous because someone could fall. The Maintenance Supervisor stated it was important to clean up water on the floor immediately because anybody could slip and fall. The facility policy stated the environment should be as free from accident hazards as possible and that safety risks and environmental hazards should be identified on an ongoing basis.
Unlabeled oxygen tubing for two residents
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to follow its Respiratory Therapy-Prevention of Infection policy for two residents by not ensuring their nasal cannula tubing was labeled when changed. Resident 11 was admitted with diagnoses including cancer of the bronchus or lung and respiratory failure, had an active order to change the oxygen cannula every week on Sunday, and was receiving continuous oxygen via nasal cannula. During observation, Resident 11's nasal cannula tubing was unlabeled, and the ADON stated it should have been dated so staff would know when replacement was needed and that weekly tubing changes were done to prevent mucus build up or infections. Resident 63 was admitted with diagnoses including metabolic encephalopathy and pleural effusion, had an H&P stating the resident had capacity to understand and make decisions, and an MDS indicating severely impaired cognition. Resident 63 had an active order to change the nasal cannula every week and as needed, every day shift, every Sunday, and the care plan directed staff to change humidification and oxygen tubing as indicated. The DON stated it was important to label oxygen tubing with the last date it was replaced to prevent residents from contracting a respiratory infection, and the facility policy stated oxygen cannula and tubing should be changed every seven days or as needed.
Expired Mustard Bottles Kept in Dry Storage
Penalty
Summary
The facility failed to discard seven mustard bottles in the dry food storage room of Kitchen 1 even though each bottle had a use-by date of 5/27/2026. During an interview in the kitchen's dry food storage room, the Dietary Supervisor stated that newly delivered dry food items are labeled with the date received and expiration date, and that items with stamped expiration dates do not need the date written on the label. The Dietary Supervisor also stated that older food items are placed at the front of the shelves and newer items at the back so foods with earlier expiration dates are used first. During a concurrent observation and interview, seven mustard bottles, each containing 13 ounces and marked with the 5/27/2026 use-by date, were found in the dry food storage room. The Dietary Supervisor stated these bottles should have been discarded to prevent possible food-borne illnesses to residents and removed them from the storage room. The DON later stated that expired food could possibly be rotten and potentially cause food poisoning when residents consume it, and that following expiration dates is important to protect residents and promote food safety.
Infection Control Failure in Kitchen Dry Storage
Penalty
Summary
The facility failed to implement infection control in accordance with its policy in Kitchen 1 when items intended for staff use were kept inside the kitchen's dry food storage room. During observation, an unlabeled resealable bag containing plastic spoons, sugar packets, coffee creamer packets, and tea bags was seen on a food shelf near canned goods and boxed food mixtures. A second unlabeled resealable bag containing plastic cup lids and a wooden caddy organizer containing individual packets of sugar, coffee creamer, hot sauce, and ketchup were also observed on the same shelf in the dry food storage room. During interview, the Dietary Supervisor stated the unlabeled bags and wooden caddy belonged to nursing staff and were used to hold leftover plastic spoons, plastic cup lids, and condiment packets. The Dietary Supervisor stated these items were not supposed to be inside the dry food storage room, which was for residents' food only, and stated it was possible a staff member could accidentally take a spoon, cup lid, or condiment packet from the unlabeled containers and give it to a resident, which could potentially lead to the spread of infection. The DON later stated that plastic spoons, plastic cup lids, and condiment packets intended for staff use should not be kept in the kitchen's dry food storage room. The facility policy titled Infection Prevention and Control Program stated the IPCP is established and maintained to provide a safe, sanitary environment and to help prevent the development and transmission of communicable disease and infections.
Pest Control Program Failed to Prevent Gnats in Resident and Care Areas
Penalty
Summary
The facility failed to have an effective pest control program for one sampled resident, Resident 15. Resident 15 was admitted on 12/31/2025 with diagnoses including Parkinson's Disease and low back pain, and a history and physical dated 3/6/2026 indicated the resident had the capacity to understand and make decisions. During a concurrent observation and interview on 6/16/2026 at 10:30 a.m., five gnats were observed flying around Resident 15's room, and one flew at the surveyor's face during the interview. Resident 15 stated the gnats had been noticed a few weeks earlier in the room and near the reception desk and were annoying to the resident and other residents. Further observations showed two gnats on the wall in Resident 15's room, and LVN 2 stated there was no food or fruit in the room to explain the gnats and killed one gnat on the wall. Additional observations found a gnat in the conference room and another in the nurses' station. The Maintenance Supervisor stated the facility had a pest control program but was unaware of the gnats until 6/16/2026. The DON stated insects should not be in a resident's room because they could get into food or belongings and were an infection risk, and also were not consistent with a homelike environment. The facility's policy stated it maintained an ongoing pest control program to keep the building free of insects and rodents.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to keep the call light within reach for one of two sampled residents, Resident 59. Resident 59 was admitted with diagnoses including morbid obesity, muscle wasting and atrophy, and COPD. The care plan for falls, last revised on 8/21/2024, included an intervention to keep the call light within Resident 59's reach and to keep Resident 59 in supervised view as much as possible. Resident 59's H&P noted an above-the-knee amputation of the left leg and that Resident 59 had the capacity to understand and make decisions. The MDS dated 3/30/2026 indicated Resident 59 was cognitively intact and dependent for toileting hygiene, shower/bathe, and personal hygiene. During a concurrent observation and interview on 6/16/2026 at 10:36 a.m., Resident 59 was lying in bed and stated nursing assistance was needed, but the call light was located on the floor behind the head of the bed. Resident 59 stated the call light was often not within reach and that Resident 59 would watch the hallway from bedside and yell at staff passing by to get help. CNA 3 later observed the call light on the floor behind the head of the bed and stated staff should make regular rounds to ensure the call light is within reach. The DON stated call lights are used so residents can get assistance when needed, that CNAs are required to make rounds at least every two hours, and that nurses should ensure the call light is within reach whenever entering a resident room.
Late Initial MDS Assessment
Penalty
Summary
The facility failed to ensure the initial MDS assessment for one resident was completed within 14 days after admission. Resident 41 was originally admitted on [DATE], and the record review showed no re-admission date. The resident’s admission record listed diagnoses of type 2 diabetes, non-Hodgkin lymphoma, and anemia. The resident’s H&P dated 4/7/2026 indicated the resident had the capacity to understand and make decisions, and the MDS indicated the resident was cognitively intact and required maximal assistance for toileting hygiene and showering/bathing. During interview and record review, the MDS Coordinator stated that a new resident’s initial MDS must be completed and submitted electronically to CMS within 14 days of admission, and that Resident 41’s initial MDS was completed, locked, and submitted late on 4/21/2026. The MDS Coordinator also stated MDS assessments should match and be consistent with a resident’s diagnoses. The DON stated MDS assessments are used to identify residents’ conditions so nursing staff know how to provide specific care, and that the facility should comply with submission deadlines for MDS assessments. The facility policy titled Resident Assessments stated comprehensive assessments are completed at intervals designated by OBRA regulations and that OBRA-required assessments include the admission assessment.
Care Plan Not Updated for HD Schedule and Fluid Restriction
Penalty
Summary
The facility failed to ensure that Resident 50 had a revised care plan for hemodialysis scheduling and fluid restriction. Resident 50 was readmitted with diagnoses including End Stage Renal Disease and dependence on renal dialysis. The history and physical dated 5/16/2026 indicated to continue hemodialysis as scheduled, and also noted that Resident 50 had fluctuating capacity to understand and make decisions. The order summary showed active orders for dialysis four times per week on Tuesdays, Thursdays, Saturdays, and Wednesdays, and a fluid restriction of 1,000 ml total per day with amounts assigned to Nursing and Dietary. The care plan, however, still reflected hemodialysis on Mondays, Wednesdays, and Fridays, with a fluid restriction of 1,000 ml per day using different Nursing and Dietary allocations than the active order. The care plan had last been revised on 3/18/2025 for the dialysis schedule and was initiated on 2/19/2026 for the fluid restriction. During interview, LVN 3 stated the resident received dialysis on Tuesdays, Thursdays, Saturdays, and had an extra HD day on Wednesdays, and stated the care plan should have been updated when the orders were received. The DON stated the care plan should be updated when there is a change with the resident, a new order, and quarterly, and that an updated care plan was important so nursing staff would know the appropriate interventions and how to properly care for the resident.
Failure to Apply Ordered Bilateral PRAFO Braces
Penalty
Summary
The facility failed to ensure that one sampled resident with bilateral ankle contractures, Alzheimer’s disease, and severely impaired cognition had both prescribed PRAFO braces applied as ordered. The resident was readmitted with contractures of both ankles and had a history and physical documenting contractures in all four limbs. The care plan identified the resident as at risk for decreased ROM, decreased mobility, decreased muscle strength, deformity, contracture, and skin breakdown, and included an intervention for the RNA to apply bilateral PRAFO braces every day, five times a week for three to four hours and to check skin integrity. The order summary also showed an active order for bilateral PRAFO braces to be applied every day five times a week for up to four hours or as tolerated. During observation, the resident was in bed with a PRAFO brace on the right lower extremity and the other brace lying on the bed. A concurrent observation and interview with an LVN confirmed that only one brace was on and stated both braces should be on to straighten the resident’s feet and prevent worsening foot drop. An RNA stated the resident wears the PRAFO braces for foot drop and should remain on for four hours. The DOR stated the PRAFO braces limit progression of the resident’s foot drop and that not wearing them may lead to progression of ankle contracture. The facility policy stated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM, including necessary equipment based on professional standards of practice.
Unlabeled Outside Food Left at Bedside
Penalty
Summary
The facility failed to implement its policy and procedure titled, Foods Brought by Family/Visitors, when an opened and unlabeled bottle of Italian dressing brought in by the resident’s family was found at the resident’s bedside. Resident 72 was admitted with HTN and DM, had moderately impaired cognition on the MDS, and the H&P indicated the resident had capacity to understand and make decisions. The MDS also indicated it was very important for the resident to have snacks available between meals and that the resident required moderate assistance with eating, oral hygiene, and personal hygiene, and maximal assistance with toileting hygiene, showering/bathing, and bed-to-chair transferring. During observations on 6/16/2026 and 6/17/2026, the opened Italian dressing remained at the bedside without a resident name or date label, despite the bottle indicating it should be refrigerated after opening. The resident stated the family had brought the dressing a couple of days earlier and that it was used for salad served in the facility. CNA 1 stated outside food should be brought to the charge nurse, checked for the correct diet and safety, labeled with the resident’s name and received date, and refrigerated in the resident’s refrigerator. The IPN stated staff should label outside food with the resident’s name and received date and store it appropriately, and the DON confirmed the bottle did not have the required labels and should have been stored in the refrigerator. The facility policy required food brought by family or visitors and left for later consumption to be labeled with the resident’s name, item, and used-by date and stored in a refrigerator.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source to the California Department of Public Health for one resident. The resident had a history of cerebral infarction with left-sided hemiparesis, lacked capacity to understand and make decisions, and had severely impaired cognitive skills with short-term and long-term memory problems. The resident also required extensive assistance with eating, oral hygiene, dressing, personal hygiene, toileting hygiene, bathing, and footwear, and had impaired range of motion on one side of the body. The resident developed a scratch on the upper lip and redness around the eyes, which later changed to purple and yellow discoloration. Multiple staff members stated they observed bruising or discoloration on the resident’s face and forearm but did not know how the resident was injured, and no one witnessed the injury. The DON stated that an injury of unknown source is one where staff do not know how it happened and that such injuries must be reported to CDPH and investigated. The DON also stated the facility determined the resident’s injuries were due to the resident hitting the bedrail because that was normal behavior, and the incident was not reported to CDPH. Facility policy stated that all resident injuries are to be investigated, that injuries of unknown source are those not observed by any person or not explained by the resident and are suspicious based on the extent, location, number, or pattern of injuries, and that suspected abuse or injury of unknown source must be reported immediately to the administrator and state licensing/certification agency. The report indicates the facility did not report the resident’s unexplained facial bruising as required.
Missing Care Plan for Fall and Bed Rail Behavior
Penalty
Summary
Failure to develop and implement a complete care plan was identified for one resident with a history of cerebral infarction and left-sided hemiparesis. The resident was admitted and later readmitted to the facility, had no capacity to understand and make decisions per the H&P, and the MDS showed severely impaired cognitive skills, short- and long-term memory problems, maximal assistance needed for several ADLs, dependence for toileting hygiene, bathing, lower body dressing, and shoes, and impaired range of motion on one side of the body. A CIC dated 5/3/2026 indicated the resident was found sitting on the floor and had abrasions to the midback, but there was no care plan in the medical record regarding the fall. Nursing progress notes dated 5/28/2026 through 5/30/2026 indicated the resident had a behavior of putting an arm in the bed rail, and a doctor progress note dated 5/28/2026 stated the resident wrapped the arms around the side rails. The DON stated the resident had a behavior of placing the right arm through the bed rail and that licensed nurses should have developed a care plan for the repetitive behavior, but no care plan regarding this behavior was found in the medical record. The facility policy on comprehensive person-centered care plans stated they should include measurable objectives, time frames, and services to attain or maintain the resident's highest practicable well-being.
Missing fall assessment and COC documentation for a resident with mobility and cognitive impairment
Penalty
Summary
The facility failed to ensure one of ten sampled residents received care and services to prevent accidents when a fall risk assessment was not completed after the resident was found sitting on the floor on 5/3/2026. The resident had been admitted and later readmitted with diagnoses including cerebral infarction and left-sided hemiparesis. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS dated 4/16/2026 indicated severely impaired cognitive skills, short- and long-term memory problems, maximal assistance for several activities of daily living, dependence for others, and impaired range of motion on one side of the body. The COC dated 5/3/2026 stated the resident was found sitting on the floor and had abrasions to the midback. The electronic medical record did not contain a Fall Risk Assessment by Nursing and/or Rehabilitation after the event. The DOR stated a post-fall screen had to be completed after a resident fall, and that a fall was when a resident’s buttocks, knees, or body touched the floor. The DOR also stated the resident should have been referred for rehabilitation assessment after the fall, and that failure to complete the screen could overlook injuries, fractures, and pain. The facility also did not complete a COC when the resident’s right arm became stuck in the bed rail. CNA 1 stated the resident’s right arm was found stuck in the gaps of the bed rail and a nurse had to remove it, after which red marks were noted on the right forearm. LVN 1 stated the resident moved a lot in bed, often placed the arm through the bed rail gaps, and had redness to the right forearm. The DON stated the resident required COC documentation for the arm getting stuck in the bed rail because the resident sustained redness to the right arm, and also stated that if changes of condition were not documented, staff would not be aware of the resident’s situation and the resident would not receive appropriate care and treatment.
Failure to Readmit Hospitalized Resident to First Available Bed per Bed-Hold Policy
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return to the first available semi-private bed following hospitalization, in accordance with its own "Bed-Holds and Returns" policy. The resident had been admitted with multiple diagnoses, including an immune disorder, type 2 DM with complications, abnormal gait and mobility, and chronic total occlusion of extremity arteries. The resident’s H&P documented that the resident could express needs but could not make medical decisions, and the MDS showed moderately impaired cognitive skills with a need for partial/moderate assistance in several ADLs. Progress notes indicated the resident was transferred to a GACH for evaluation and treatment related to failure to thrive, with a seven-day bed hold in place, and later transferred to an LTACH where physician notes documented that the resident had improved and stabilized. When the LTACH sent an inquiry fax requesting the resident’s readmission, the facility refused to readmit the resident, citing the lack of an available Candida auris isolation bed. However, review of the facility census and interviews with the Marketing staff and ADON showed that several semi-private rooms each had one female bed available on the relevant dates, and that the facility could have arranged four rooms to make one room available during that period. The Marketing staff and ADON both acknowledged that the facility could have made a specific room available to readmit the resident, as they later did for another resident who was readmitted to that same room. Further review with the administrator confirmed that the facility received the LTACH inquiry and declined readmission for the resident, while subsequently making the same room available to admit another resident. The Infection Preventionist stated that the facility had no current C. auris isolation residents and that an empty room could have been designated as a C. auris isolation room to allow the resident’s return. An interview with another resident indicated that this resident had never been asked to change rooms but would have agreed if asked, and there were no progress notes documenting any refusal to change rooms. The facility’s "Bed-Holds and Returns" policy stated that residents seeking to return after the state bed-hold period must be allowed to return to their previous room if available or immediately to the first available bed, provided they still require facility services and are eligible for Medicare or Medicaid services, conditions that were met for this resident.
Failure to Ensure Call Lights Within Reach for High-Risk Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, both of whom were identified as high risk for falls and had significant cognitive and physical impairments. For one resident, who had muscle wasting, atrophy, impaired cognition, and was dependent on staff for all activities of daily living, the call light was observed hanging on the top of the bed board and not within the resident's reach while the resident was asleep. The care plan for this resident specifically required that the call light be within reach and that the resident be reminded to call for assistance with all transfers. The facility's Infection Prevention Nurse confirmed during observation that the call light was not accessible, and the DON stated that call lights should always be within reach for safety. For the second resident, who had anemia, muscle weakness, severely impaired cognition, used a wheelchair, and required substantial assistance for toilet transfers, the call light was not visible or within reach while the resident was in her wheelchair and verbally requesting assistance. The Infection Prevention Nurse had to retrieve and place the call light within reach during the observation. The DON confirmed that this resident was also at high risk for falls and reiterated the importance of call lights being accessible at all times. The facility's policy required that call lights be within easy reach of residents when in bed or in a chair.
Inaccurate MDS Assessment of Hearing and Discharge Status
Penalty
Summary
The facility failed to accurately encode assessment information on the Minimum Data Set (MDS) for two residents, resulting in inaccurate documentation of hearing capability and discharge status. For one resident, the MDS did not reflect the resident's significant hearing impairment, despite multiple observations and interviews indicating the resident had difficulty hearing, did not possess a hearing aid, and expressed a desire for one. Certified Nurse Assistants reported needing to speak loudly, slowly, and directly in front of the resident, and the resident confirmed reading lips and being hard of hearing. However, the MDS Coordinator stated that the resident did not complain of hearing difficulty at the time of assessment, leading to the omission of this need in the MDS. For another resident, the discharge status was incorrectly coded on the MDS as a transfer to a general acute care hospital, when in fact the resident was discharged to a skilled nursing facility (SNF) for continued long-term care. Multiple records, including progress notes, order summaries, and discharge summaries, consistently documented the transfer to a SNF. During a review, the MDS nurse acknowledged the error and confirmed that the MDS should have been coded to reflect discharge to a SNF. The facility's policies and procedures require accurate and comprehensive resident assessments in accordance with federal and state regulations. The inaccuracies in the MDS assessments for both residents were contrary to these policies and had the potential to negatively affect the quality of care and services provided.
Failure to Monitor Fluid Intake and Weight Changes for Two Residents
Penalty
Summary
The facility failed to implement its own policies and procedures regarding nutritional management and person-centered care plans for two residents. For one resident with muscle wasting, atrophy, and low sodium levels, there was a physician order for fluid restriction to 1,200 cc per day. Despite this, staff did not monitor or document the resident's fluid intake as required, and a water pitcher was left at the bedside. Multiple staff interviews confirmed that fluid intake was neither tracked nor recorded, and the resident's care plan did not address the fluid restriction. The facility's policy required fluid restrictions to be documented and integrated into the care plan, and water pitchers should not be available at the bedside unless evaluated as appropriate. For another resident with end-stage renal disease and diabetes, a significant weight gain of over 15 pounds was noted. The registered dietitian recommended weekly weights for four weeks, and the physician approved this recommendation. However, there was no order placed for weekly weights, and no weight measurements were recorded for a period of nearly two weeks. The DON acknowledged that the order for weekly weights was overlooked, despite the resident's risk for fluid retention due to dialysis. The facility's own policies required timely implementation and documentation of nutritional recommendations within 72 hours and the development of comprehensive, person-centered care plans within specified timeframes. In both cases, the facility did not follow these policies, resulting in a lack of monitoring and documentation for residents with significant health risks related to fluid and nutritional management.
Failure to Provide Ordered Gastrostomy Tube Site Care
Penalty
Summary
The facility failed to provide necessary care and services for gastrostomy tube (GT) sites as ordered by physicians and as indicated in the care plans for two residents. Both residents had significant neurological impairments, including hemiplegia, hemiparesis, and severely impaired cognition, and were dependent on staff for most activities of daily living. Physician orders and care plans for both residents required licensed staff to clean the GT site with normal saline solution, pat dry, cover with a drain sponge, and secure with retention tape daily and as needed. Care plans also specified GT site care per protocol every shift and as needed, with goals to keep the GT insertion site free from infection and complications. Direct observations revealed that neither resident had a drain sponge dressing or securement at the GT site at the time of inspection. Staff interviews confirmed that the GT sites were not covered or secured as ordered. The facility's policy and procedure for gastrostomy site care required the application of a T-drain sponge and retention tape to promote cleanliness and protect the site from irritation, breakdown, and infection. The Director of Nursing confirmed that the GT site should be kept clean, covered, and secured as ordered to prevent infection, dislodgement, and skin irritation.
Failure to Provide Safe and Appropriate Respiratory Care During Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who were receiving oxygen therapy, in accordance with its own policies and professional standards. For one resident with pneumonia and dysphagia, observations revealed that the nasal cannula tubing was touching the floor while the resident was receiving oxygen via concentrator. Both a licensed vocational nurse and the Director of Nursing confirmed that the tubing should not touch the floor due to the risk of contamination, and facility policy required replacement of tubing if it became soiled or contaminated. For another resident with muscle wasting, atrophy, and impaired cognition, the nasal cannula tubing was observed resting on top of a suction bottle with visible white secretions, rather than being stored in a plastic bag when not in use as required by facility policy. The Infection Prevention Nurse and the DON both acknowledged that this practice did not comply with infection control protocols and could lead to cross-contamination. Record reviews confirmed that both residents had active physician orders for continuous oxygen therapy, and staff interviews indicated awareness of the need for continuous administration and proper handling of oxygen equipment. However, the observed practices did not align with the facility's written procedures for infection prevention and oxygen administration, resulting in a deficiency related to respiratory care and resident safety.
Deficient Food Storage and Ice Machine Sanitation
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation standards in two specific instances. First, during an observation in the dry storage area, a bag of tortillas was found left open at the top. The Dietary staff confirmed that the bag should not have been left open, as it could allow contaminants to enter and compromise the freshness and safety of the food. The facility's policy requires that food be stored in a manner that maintains the integrity of the packaging until use, and staff interviews confirmed that the open bag was not in compliance with these standards. Second, the kitchen ice machine was observed to have a pink tinged and dark substance inside the ice bin, which could be easily removed with a paper towel. The Maintenance Supervisor and DON acknowledged that these substances should not be present, as they could contaminate the ice. The facility's policy and the manufacturer's manual both require regular cleaning and maintenance of the ice machine to ensure a safe and sanitary supply of ice. These lapses in food storage and equipment sanitation had the potential to result in foodborne illness.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy and procedure for three of six sampled residents. Specifically, the facility did not complete the required McGeer Criteria forms for residents who were prescribed antibiotics, as confirmed by both the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON). The McGeer Criteria forms are used to screen residents before initiating antibiotic therapy to ensure the appropriateness of antibiotic use. For each of the three residents, antibiotics were prescribed and administered for various infections, including peritonitis, abscess, MSSA infection, pseudomonas bacteremia, pneumonia, and chronic respiratory failure, without documented evidence that the stewardship protocol was followed. Record reviews showed that one resident was admitted with multiple antibiotic resistance and was prescribed Cephalexin for a knee abscess, another was treated with Amoxicillin-Clavulanate for MSSA and pseudomonas bacteremia, and a third received both Amoxicillin-Clavulanate and Doxycycline for pneumonia. Despite these prescriptions, the facility did not document the use of the McGeer Criteria to justify antibiotic therapy, as required by their policy. Interviews with facility staff confirmed that the forms were not completed and that the stewardship process was not followed for these residents.
Failure to Complete POLST and Advance Directive Forms Upon Re-Admission
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) and Advance Directive (AD) Acknowledgement Form were completed upon the re-admission of a resident. Record review showed that the resident, who had diagnoses including diabetes mellitus, end stage renal disease, and hypertension, was readmitted to the facility but did not have updated POLST and AD forms as required by facility policy. The resident's Minimum Data Set indicated moderately impaired cognition and a high level of dependence on staff for daily activities. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the required POLST and AD Acknowledgement Form were not completed or updated at the time of re-admission. Facility policy states that these forms should be completed and reviewed with every admission and re-admission to ensure care aligns with the resident's current wishes. The absence of these documents was verified through review of the resident's medical record and the facility's electronic health record system.
Failure to Provide Communication Device for Non-English Speaking Resident
Penalty
Summary
A resident admitted with diagnoses including hypertension, atrial fibrillation, and malignant neoplasm of the lung was identified as speaking only Cantonese and requiring an interpreter to communicate with healthcare staff, as documented in the resident's Admission Record and Minimum Data Set. During observation and interview, it was found that the resident did not have a communication board or any communication device at the bedside, despite being alert and needing such a device to communicate needs to staff. Certified Nurse Assistant 4 confirmed that the resident spoke only Chinese and should have had a communication board available. The Director of Nursing also stated that all alert, non-English speaking residents should be provided with a communication board in the language they understand. Review of the facility's policy indicated that residents with language barriers should be provided with visual aids or devices to facilitate communication, but this was not implemented for the resident in question.
Failure to Assess and Report Resident's Ongoing Skin Condition and Symptoms
Penalty
Summary
The facility failed to adequately assess and report a resident's ongoing skin condition and associated symptoms to the physician, despite repeated complaints and documented observations. The resident, who had a history of Type 2 diabetes, neuralgia, neuritis, and obesity, was admitted with chronic vaginal yeast infection and required substantial assistance with mobility and hygiene. Care plans directed staff to monitor and report complaints of pain, itching, and skin changes, and physician orders included a gynecological consult for the chronic infection. Over several months, the resident repeatedly complained of vaginal and buttock itching and discomfort, with documented episodes of redness and flaky skin. Despite these ongoing symptoms and the care plan's instructions, the resident was not scheduled for the gynecological consultation as ordered. Observations revealed the resident experiencing significant discomfort, using her hands to scratch, and reporting that topical medication provided only temporary relief. The resident also reported that the itching affected her sleep and caused anxiety. Interviews with staff indicated that CNAs reported the resident's complaints to the charge nurse, but the treatment nurse was not informed of new symptoms, and the director of nursing confirmed that no new orders were obtained for some episodes. The treatment nurse only assessed the resident when issues were reported, and the LVN relied on CNAs to communicate changes. The facility's policy required high-quality care and prompt reporting of changes, but this was not consistently followed, resulting in unrelieved symptoms for the resident.
Failure to Provide Hearing Services for Resident with Hearing Impairment
Penalty
Summary
The facility failed to provide necessary care and services to meet the needs of a resident with hearing impairment. The resident, who had diagnoses including encephalopathy, acute pulmonary edema, and chronic kidney disease, was readmitted to the facility and was noted to have severely impaired cognition and require substantial assistance with daily activities. Despite clear indications of hearing difficulty—such as the resident stating he could not hear, needing to read lips, and expressing a desire for a hearing aid—there was no evidence that the resident was scheduled for an audiology consult or provided with hearing aids. Staff interviews confirmed that the resident had no hearing aid, had difficulty hearing, and required staff to speak loudly or slowly and be positioned in front of him to communicate effectively. A review of the resident's belongings inventory did not indicate possession of a hearing aid, and facility staff consistently reported the resident's ongoing hearing challenges. The facility's policies required assistance in obtaining assistive devices like hearing aids and mandated that recommendations for such devices be based on comprehensive assessment and documented in the care plan. However, these steps were not taken for the resident, resulting in continued communication barriers and unmet needs related to hearing assistance.
Failure to Reposition Resident with Stage 4 Pressure Ulcer
Penalty
Summary
A resident with a history of encephalopathy, hepatomegaly, and COPD was readmitted to the facility and had a documented Stage 4 pressure ulcer on the sacro-coccyx. The resident's care plan and physician orders required repositioning every two hours and the use of a low air loss mattress to prevent further skin breakdown. Observations and interviews revealed that the resident was not repositioned according to the facility's turning schedule, remaining in a supine position when they should have been turned to the left or right side. Staff interviews confirmed awareness of the repositioning protocol, and the resident was noted to require substantial assistance for mobility and turning. Despite established protocols and staff knowledge, the resident was not consistently repositioned as required. The facility's policy emphasized the importance of high-quality care and adherence to evidence-based practices, including regular repositioning to promote wound healing and prevent further deterioration. The failure to reposition the resident as scheduled placed the resident at risk for worsening of the existing Stage 4 pressure ulcer.
Failure to Provide Adequate Supervision and Care Planning for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, hemiparesis, and Alzheimer's disease, who was assessed as having severely impaired cognition and was dependent on staff for all activities of daily living (ADLs) and bed mobility, was not provided with adequate supervision during care. The resident was identified as high risk for falls and required two-person assistance for all ADLs, including turning and repositioning. However, documentation and staff interviews revealed that the resident was turned and changed by only one certified nursing assistant (CNA), resulting in the resident rolling off the bed and falling to the floor. The incident was confirmed by progress notes and interviews with facility staff, who acknowledged that two-person assistance was necessary for the resident's safety during such activities. Additionally, the facility failed to develop and implement an individualized, person-centered care plan addressing the resident's high risk for falls prior to the incident. Despite the resident's documented needs and risk factors, there was no care plan in place to guide staff in providing the necessary care and services to prevent falls and injuries. Facility policies required comprehensive care plans to be developed within a specified timeframe after assessment, but this was not completed for the resident before the fall occurred.
Failure to Secure Foley Catheter Tubing as Required by Policy
Penalty
Summary
A deficiency was identified when a resident with an indwelling Foley catheter was observed with the catheter tubing unsecured inside their night pants, and the catheter bag hanging at the back of the wheelchair. The securement device intended to anchor the catheter tubing was found to be broken, and the tubing was not secured to the resident's thigh as required by facility policy. Licensed Vocational Nurse 4 confirmed that the tubing should have been secured to prevent pinching, pulling, or trauma during movement. The resident in question had a history of diabetes mellitus, hypertension, anxiety, and severely impaired cognition, and required varying levels of assistance with daily activities. The care plan specified the use of an indwelling catheter for obstructive uropathy, with a goal to prevent catheter-related trauma. Both the Director of Nursing and facility policy confirmed that the catheter should be anchored to reduce friction and movement at the insertion site, but this was not done at the time of observation.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to attempt and document the use of appropriate alternative interventions before installing bilateral side rails for a resident. The resident in question had a history of hemiplegia, hemiparesis, and osteoarthritis, and was assessed as having severely impaired cognition. The resident was dependent on staff for all activities of daily living, including oral hygiene, toileting, showering, dressing, and personal hygiene. During observation, the resident was found in bed with both upper side rails raised, and staff confirmed the resident was confused and unable to move one side of her body. Record review and interviews with facility staff, including the DON, revealed there was no documented evidence that alternatives to side rails were attempted or evaluated prior to their installation. The facility's policy required that alternatives be tried and documented, and that an interdisciplinary evaluation and informed consent be obtained before bed rails are used. The lack of documented attempts at alternatives and evaluation placed the resident at risk for entrapment and physical injuries.
Arbitration Agreement Lacked Venue Selection for Both Parties
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement for one resident included provisions for selecting a venue that would be convenient for both the facility and the resident or the resident's responsible party. During a review of the admission record, it was found that the arbitration agreement signed by the resident did not specify how a mutually convenient venue would be selected. The Admission Director confirmed that the agreement used was an outdated form from a previous director and acknowledged the importance of having a convenient location for both parties to attend the arbitration hearing. The facility's policy and procedure on binding arbitration agreements, revised in May 2024, states that arbitration agreements should provide for the selection of a venue that meets the needs of both parties and that the venue should be agreed upon by both. The policy also notes that convenience for the resident or representative may be determined by their ability to get to the venue. However, the agreement signed by the resident did not reflect these requirements, leading to the deficiency.
Failure to Implement Infection Control Precautions for Resident with MRSA
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident with MRSA-positive wounds who was placed on Enhanced Standard Precautions (ESP). Despite the resident's diagnosis and orders for topical antibiotic treatment, there was no ESP signage posted outside the resident's room, and no personal protective equipment (PPE) cart was available at the entrance. Observations revealed that staff, including the treatment nurse, did not wear gowns while performing wound care, and both the treatment nurse and infection prevention nurse confirmed that appropriate PPE and signage were not in place as required by facility policy. Interviews with facility staff, including the treatment nurse, infection prevention nurse, and director of nursing, confirmed that the resident should have been placed on contact precautions due to MRSA of the wounds. Facility policies reviewed indicated that contact precautions and enhanced barrier precautions require the use of gowns and gloves during high-contact care activities for residents with multidrug-resistant organisms (MDROs). The lack of signage, PPE availability, and adherence to PPE protocols during wound care constituted a failure to follow established infection control procedures.
Deficiency in Resident Room Square Footage Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms for sixteen out of thirty-two resident rooms. This was determined through observation, interviews, and record review, which showed that the affected rooms did not meet the square footage requirement based on the number of beds in each room. The facility administrator acknowledged the deficiency and indicated that a waiver was being requested for these rooms, noting that there had been no changes to bed occupancy in the affected rooms. Despite the deficiency in room size, observations during the survey period indicated that residents had adequate space for mobility and storage, and staff were able to provide care without difficulty. Residents interviewed reported no issues with maneuvering mobility devices such as wheelchairs and walkers within their rooms, and staff confirmed that there was sufficient space to use necessary equipment and provide care. The deficiency was identified based on the physical measurements of the rooms in relation to regulatory requirements, not on observed negative outcomes for residents.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse involving two residents to the State Licensing and Certification Agency, the Ombudsman, and local law enforcement within the required two-hour timeframe. This deficiency was identified during a review of the facility's records and interviews with staff. The incident occurred when one resident allegedly came into contact with another resident's arm in the dining hall. The report of the incident was faxed to the State Licensing and Certification Agency several hours later, at 12:07 pm, rather than within the mandated two-hour window. Interviews with various staff members, including Licensed Vocational Nurses, a Registered Nurse Supervisor, the Quality Assurance Nurse, and the facility's Administrator, confirmed that the facility's policy required immediate reporting of such incidents to ensure resident safety and timely investigation. The Administrator acknowledged the delay in reporting the incident, which was contrary to the facility's policy and procedure on abuse, neglect, exploitation, or misappropriation. The facility's policy, dated September 2022, clearly stated that any suspicion of abuse must be reported immediately, defined as within two hours, to the appropriate authorities.
Improper Milk Temperature Handling in Facility
Penalty
Summary
The facility failed to ensure that milk drinks were prepared at the appropriate temperature as per their Policy and Procedure titled, Food Receiving and Storage. During an observation in the facility's kitchen, it was noted that two out of three sampled glasses of milk had temperatures exceeding 41 degrees Fahrenheit, which is above the safe temperature range. Dietary Aide 1 (DA 1) confirmed that the milk was at 56 degrees Fahrenheit, which is not within the normal temperature range, and acknowledged that milk at this temperature could make residents sick. DA 1 also mentioned that the milk should be discarded if it was not in the normal temperature range. Further interviews revealed discrepancies in the understanding of the correct temperature range for milk. DA 2 stated that the milk should be below 40 degrees Fahrenheit, while the Dietary Supervisor (DS) indicated that the temperature should be between 32 and 41 degrees Fahrenheit. The DS also confirmed that milk above 41 degrees Fahrenheit should be discarded as it enters the potentially hazardous food temperature zone, which could lead to foodborne illness. The facility's policy, revised in November 2022, specifies that potentially hazardous foods should be stored at or below 41 degrees Fahrenheit to prevent the rapid growth of pathogenic microorganisms.
Failure to Provide One-to-One Activities for Residents
Penalty
Summary
The facility failed to provide one-to-one activities for two residents, as required by their care plans, over a five-day period. Resident 33, who was admitted with hemiplegia, hemiparesis, and dementia, required one-to-one activity visits for social interaction and mental stimulation. However, observations showed that the resident was sleeping during multiple checks and was only assisted with lunch, indicating a lack of engagement in planned activities. The Minimum Data Set (MDS) for Resident 33 was incomplete, with the section on daily and activity preferences left blank. Similarly, Resident 34, who has traumatic brain injury and quadriplegia, was also not provided with the necessary one-to-one activities as outlined in their care plan. The care plan specified the need for sensory stimulation and reality awareness, yet the resident was observed lying in bed awake without engagement. The Activities Assistant admitted to not providing one-to-one activities to these residents because they were not on the schedule, despite the facility's policy requiring such activities for residents unable to leave their rooms. The MDS for Resident 34 was also incomplete, lacking the assessment of daily and activity preferences.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders for continuous oxygen administration for two residents, leading to potential health risks. Resident 15, who was readmitted with diagnoses including dependence on supplemental oxygen and chronic respiratory failure with hypoxia, was observed without the nasal cannula in place, despite an order for continuous oxygen at 2 liters per minute. The nasal cannula was found coiled on the floor, and a Licensed Vocational Nurse (LVN) confirmed the resident's need for continuous oxygen due to their respiratory disorder. Similarly, Resident 58, with diagnoses including hemiplegia, hemiparesis, and atelectasis, was observed with the nasal cannula lying on the bedsheets instead of being used as ordered. The oxygen machine was running, but the cannula was not in the resident's nostrils. An LVN confirmed the resident's continuous oxygen order and the potential for respiratory distress if not administered. The facility's policy on oxygen administration requires verification and adherence to physician's orders, which was not followed in these cases.
Inaccurate Staffing Information Posted
Penalty
Summary
The facility failed to post accurate staffing information for two consecutive days, which included the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care. The posted staffing information inaccurately included the hours of the Minimum Data Set (MDS) nurse, who was not directly responsible for resident care. Additionally, the staffing information did not include the name of the facility, which is a requirement according to the facility's policy and procedures. This discrepancy was observed during inspections on two separate days. During an interview and record review, the Director of Staff Development (DSD) acknowledged that the staffing information for the inspected days was based on projected hours rather than actual hours worked. The DSD misunderstood the role of the MDS nurse, believing that the nurse's assessment activities constituted direct care. The facility's policy requires that staffing information be computed and posted within two hours of the beginning of each shift, and it should reflect the staff responsible for direct resident care, such as medication administration and assistance with activities of daily living.
Inadequate Sanitization in Kitchen
Penalty
Summary
The facility failed to ensure that the quaternary ammonium sanitizer solution used for cleaning the food preparation area and the chlorine level in the dishwasher met the required concentration levels for effective sanitization. During an inspection of the facility's kitchen, it was observed that the sanitizing solution in two red buckets had a concentration of 0 parts per million (ppm), whereas the recommended concentration for effective cleaning was 100 ppm. Additionally, the chlorine level in the Low-Temperature Dishwashing Machine was found to be 10 ppm, significantly below the recommended range of 50-100 ppm. These deficiencies were identified during an inspection conducted with the Registered Dietitian, who confirmed the importance of maintaining the required concentration levels to prevent cross-contamination and foodborne illnesses. Interviews with the facility's Dietary Supervisor revealed that the facility's policy required the concentration of sanitizing solutions to be tested regularly to ensure effectiveness. The facility's Policy and Procedure documents indicated that the quaternary solution should be tested at least every shift or when the solution appears cloudy, and replaced if the concentration falls below 200 ppm. Similarly, the dishwashing policy required the chlorine level in the dishwasher to be within the specified range to ensure proper sanitization of dishes. The failure to adhere to these policies and procedures resulted in the potential risk of dishes and food preparation areas not being properly sanitized, which could lead to foodborne illnesses among residents.
Infection Control Failures in Resident Care
Penalty
Summary
The facility failed to implement proper infection control measures for two residents, leading to potential cross-contamination and infection risks. For Resident 15, who was readmitted with respiratory disorders and required supplemental oxygen, the nasal cannula was found on the floor. Despite recognizing the need for discarding the contaminated nasal cannula, Licensed Vocational Nurse 3 placed it back into a plastic bag, contrary to the facility's infection prevention policy. The Interim Director of Nursing confirmed that the contaminated nasal cannula should have been discarded to prevent infection. For Resident 41, who was dependent on renal dialysis and required Enhanced Barrier Precautions (EBP) during high-contact care activities, Certified Nursing Assistant 3 failed to wear the required personal protective equipment during a linen change. Despite the presence of an EBP sign outside the resident's room, CNA 3 did not wear an isolation gown, mistakenly believing EBP was only necessary during close contact. The Infection Prevention Nurse confirmed that EBP should be followed for residents with dialysis access, as indicated in the facility's policy.
Failure to Notify Physician of Skin Condition Change
Penalty
Summary
The facility failed to notify the physician of a change in skin condition for a resident, identified as Resident 18, which was a violation of their policies and procedures regarding skin conditions. Resident 18, who was admitted with diagnoses including hemiplegia, hemiparesis, and aphasia, showed a small scab on the side of his upper abdomen during an observation. Despite the resident's inability to verbally communicate effectively, the facility did not document or report this new skin condition to the physician, nor was there an order for skin treatment. The Wound Care Nurse confirmed the absence of documentation and emphasized the importance of notifying the physician to ensure appropriate treatment. The deficiency was further compounded by communication breakdowns among the staff. Certified Nursing Assistant 1 reported the resident's complaint of itching to the Interim Director of Nursing, who then passed the information to Licensed Vocational Nurse 5. However, LVN 5, who was occupied with medication pass, did not effectively communicate the issue to Quality Assurance Nurse 1, who later stated there was no endorsement on the communication board regarding the resident's condition. Additionally, another CNA observed the rash but assumed it was an existing condition. Eventually, the resident's physician diagnosed the rash as contact dermatitis and discontinued contact isolation, highlighting the facility's failure to follow its policy and ensure timely medical intervention.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding the facility-initiated discharge of a resident. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who had been admitted with diagnoses including metabolic encephalopathy and acute metabolic acidosis, was transferred to an acute care hospital on two occasions. However, there was no documentation indicating that the Notice of Proposed Transfer/Discharge (NPT) was provided to the Ombudsman for these transfers. Quality Assurance Nurse 2 confirmed that the facility's procedure involved faxing the NPT to the Ombudsman's office and retaining a confirmation of the fax in the resident's record. Despite this procedure, there was no evidence of such documentation for the transfers on the specified dates. The facility's policy on emergency transfers or discharges included a requirement for notifying the Ombudsman, which was not adhered to in this case.
Failure to Reposition High-Risk Resident
Penalty
Summary
The facility failed to adhere to the care plan for Resident 58, who was at high risk for skin breakdown due to conditions such as hemiplegia, hemiparesis, and limited mobility. The care plan, dated 12/24/2021, required staff to assist in repositioning Resident 58 every two hours. However, records and interviews revealed that Resident 58 was not turned or repositioned on several occasions: from 4:00 PM to 10:00 PM on 5/17/2024, from 4:00 AM to 6:00 AM on 5/20/2024, and at 6:00 AM on 5/22/2024. This lack of adherence to the repositioning schedule was confirmed by Licensed Vocational Nurse 1, who acknowledged that Resident 58 was dependent on staff for turning and had a history of pressure injuries. The Interim Director of Nursing also confirmed the failure to document and perform the required repositioning for Resident 58 on the specified dates. The facility's policy, revised in 5/2013, mandates that residents in bed should be repositioned at least every two hours. The failure to follow this policy and the care plan placed Resident 58 at risk for skin breakdown and potential development of pressure injuries, as the resident was unable to move independently and had a history of such injuries.
Failure to Provide Daily Wound Care Treatment
Penalty
Summary
The facility failed to provide daily wound care treatment as ordered for a resident with an unstageable pressure ulcer on the left heel. The resident was admitted with conditions including cellulitis, peripheral vascular disease, and hypertension, and was at risk for developing pressure ulcers. A physician's order was placed for daily treatment of the pressure ulcer starting on 5/16/2024, but the treatment was not initiated until 5/18/2024, resulting in missed treatments on 5/16/2024 and 5/17/2024. The Treatment Administration Record (TAR) for these dates was blank, indicating that the treatment was not performed as required. The Wound Care Nurse confirmed that the treatment was supposed to be done daily, and the Quality Assurance Nurse admitted to incorrectly entering the order as every other day instead of daily. This error led to the missed treatments, which could potentially worsen the resident's condition. The Interim Director of Nursing also acknowledged the blank spaces in the TAR and the associated risk of the wound worsening or becoming infected due to the missed treatments. The facility's policy on medication orders requires specifying the treatment, frequency, and duration, which was not adhered to in this case.
Failure to Monitor and Report UTI Symptoms in Resident with Catheter
Penalty
Summary
The facility failed to provide appropriate care to prevent a urinary tract infection (UTI) for a resident with an indwelling catheter. The resident, who was admitted with dementia and obstructive uropathy, required monitoring every shift for signs and symptoms of UTI, as indicated in their care plan. However, the staff did not monitor the resident's urine output effectively, as evidenced by the presence of cloudy urine with off-white sediments observed by surveyors. Despite these signs, there was no documented evidence that the physician was notified promptly, which is a requirement according to the facility's policy and procedures. During observations, the resident expressed a lack of understanding about the need for the catheter, and the Licensed Vocational Nurse (LVN) on duty was unaware of the resident's condition until informed by the surveyor. The LVN acknowledged that the resident's urine output should have been monitored and reported to the physician to prevent the worsening of the resident's medical condition. This oversight in communication and monitoring placed the resident at risk for infection due to delayed treatment.
Failure to Reassess Pain After Medication Administration
Penalty
Summary
The facility failed to reassess pain for a resident after administering pain medication, resulting in the resident continuing to experience pain. The resident, who was admitted with diagnoses including age-related osteoporosis and muscle wasting, had moderately impaired cognition and required maximal assistance with various movements. On a specific day, the resident complained of knee pain through a phone interpreter, rating the pain as annoying and later as 8 out of 10. A Licensed Vocational Nurse (LVN) applied diclofenac gel to the resident's knees but did not reassess the resident's pain afterward, relying instead on the resident to report if the pain persisted. The resident confirmed that the nurse did not return to check on the pain level after the medication was applied. The facility's policy on pain assessment and management requires monitoring the resident's response to interventions and reassessing pain to ensure it is adequately controlled, which was not followed in this instance.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to explore and implement appropriate alternatives to bed rails before their installation for a resident, identified as Resident 59. The resident, who was admitted with dementia and diabetes mellitus, was observed in a low bed with quarter-length bed rails on both sides. Despite being alert and able to move side to side without assistance, the bed rails were kept up as per a charge nurse's instruction, without documented evidence of alternative measures being attempted. The Certified Nursing Assistant (CNA) was unaware of the reason for the bed rails, indicating a lack of communication and assessment. The Interim Director of Nursing (IDON) confirmed that the bed rails were installed at the family's request for bed mobility, but the facility's records lacked documentation of any prior attempts to use alternatives such as roll guards, foam bumpers, or lowering the bed. The facility's policy required such alternatives to be tried before resorting to bed rails, and an assessment for entrapment risk should have been conducted. The IDON acknowledged the potential hazard posed by the bed rails, which could lead to serious injury or death due to entrapment, highlighting the deficiency in following the facility's procedures.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident on psychotropic drugs was free from unnecessary medications by not attempting a Gradual Dose Reduction (GDR) for the use of Quetiapine Fumarate. The resident, who was admitted with diagnoses including dementia and diabetes mellitus, was prescribed Quetiapine Fumarate 25 mg three times a day for bipolar disorder, specifically for striking out. Despite having only one episode of striking out in the past 22 days, the resident's total daily dose of Quetiapine Fumarate was increased from 50 mg to 75 mg without adequate indication. The Interim Director of Nursing (IDON) acknowledged that the resident's medical record did not contain information of a past or recent failed attempt of GDR to justify that it would be clinically contraindicated. The facility's policy required a GDR attempt within the first year in two separate quarters unless clinically contraindicated, and annually thereafter. The lack of a GDR attempt placed the resident at risk for adverse drug reactions.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 16 out of 32 resident rooms met the regulatory requirement of providing at least 80 square feet per resident in multiple resident bedrooms. During an observation conducted on May 23, 2024, it was noted that several rooms, including Rooms 2, 3, 4, 5, 6, 8, 10, 11, 22, 24, 28, 29, 30, 31, 32, and 33, did not meet this requirement. These rooms had varying numbers of beds, with some rooms having up to four beds, all of which were occupied. Despite the deficiency, there were no complaints from residents regarding the space, and observations indicated that there was sufficient space for residents and staff to move around, store personal items, and accommodate necessary medical equipment. The Operations Manager acknowledged the deficiency, stating that the facility had 16 rooms that did not meet the 80 square feet per resident requirement. The facility had submitted a room waiver request to address this issue, seeking a waiver for the room size per bed for the identified rooms. The waiver request detailed the number of beds and the total room size in square feet for each of the deficient rooms. Despite the facility's efforts to manage the space effectively, the deficiency remained due to the non-compliance with the specified room size requirements.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Monte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Manor Conv Hosp | 0.3 mi | ★★★★★ | 22 | 0 |
| Greater El Monte Community Hos | 1.1 mi | ★★★★★ | 13 | 0 |
| Madera Post Acute Center | 1.4 mi | ★★★★★ | 16 | 0 |
| Rosemead Healthcare Center | 1.7 mi | ★★★★★ | 24 | 0 |
| Eastland Subacute And Rehabilitation Center | 1.8 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.