Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vernon Healthcare Center during CMS and state inspections, most recent first.
Failure to Timely Report Injury of Unknown Origin: A resident with COPD, dysphagia, dementia, schizophrenia, and moderate cognitive impairment was found with blood on the face, bed, clothes, and floor, along with an actively bleeding laceration. Hospital evaluation showed nasal bone fractures, a frontal scalp hematoma, and a left eyebrow laceration requiring sutures. Staff did not witness the cause of the injury, the resident could not explain what happened, and the DON and ADM stated the event was not reported to CDPH within the required 2 hours because it was assumed to be a fall.
Failure to Thoroughly Investigate Injury of Unknown Origin: A resident with dementia, schizophrenia, COPD, dysphagia, weakness, and dependence for ADLs was found with blood on his face, bed, clothes, and floor, along with an actively bleeding laceration. Hospital evaluation showed bilateral nasal bone fractures, a frontal scalp hematoma, and a left eyebrow laceration requiring sutures. The DON did not interview roommates or evening-shift staff, and both an LVN and a CNA stated they were not interviewed as part of any investigation, despite facility policy requiring prompt, thorough investigation of unexplained injuries.
Failure to Maintain Ordered 1:1 Monitoring: A resident with schizophrenia, dementia, cognitive impairment, akathisia, and behavioral disturbances had a care plan for ongoing 1:1 monitoring due to unsafe behaviors and impaired safety awareness. Staff later found the resident with blood on his face, bed, clothes, and floor, with an actively bleeding laceration near the eye, and he was sent to a GACH. An LPN reported no staff were present in the room, the resident could not explain the injury, and the DON stated the evening assignment had been changed from continuous 1:1 to hourly checks, with no documentation that true 1:1 monitoring was provided.
Failure to Notify Physician of Repeated Medication Refusals: A resident with bipolar disorder, atrial fibrillation, and HTN repeatedly refused scheduled Depakote, Eliquis, Losartan, and Risperdal, but the progress notes did not show that the physician was notified. The resident had moderately impaired decision-making skills and no capacity to consent, and facility policy required the prescribing provider to be notified of medication refusal.
A resident with schizophrenia, COPD, and DM had fluctuating decision-making capacity and moderate cognitive impairment, and a change in condition documented right ear pain. During record review, staff found no specific comprehensive care plan addressing the ear pain. An LVN stated the care plan should be individualized and support continuity of care, and the DON stated care plans are important to address resident concerns and show the facility's plan of action.
A facility failed to document behavior monitoring for two residents receiving psychotropic medications. One resident with schizophrenia was ordered Divalproex and Seroquel for striking out, verbal aggression, and angry outbursts, but the MAR lacked behavior tracking. Another resident with ADHD, MDD, and anxiety was ordered Bupropion for depression manifested by self-isolation, but the MAR also lacked behavior monitoring. The DON stated behavior documentation was needed to evaluate continued use and dose adjustment of psychotropic medications.
A resident with schizoaffective disorder, dementia with behavioral disturbance, and severe cognitive impairment was observed walking in the hallway in a diaper without pants while escorted by a CNA. The CNA stated the resident often did this and acknowledged it could be embarrassing, and the DON stated the resident’s dignity was not being respected and was exposed. The facility policy required residents to be cared for with dignity and respect and to be encouraged and assisted to dress in their own clothes.
Failure to Report Injury of Unknown Source: A resident with DM, bipolar disorder, schizophrenia, HTN, anemia, and cognitive impairment was found with an unexplained right forearm wound and severe pain, then sent to the GACH for evaluation. The resident could not say how the injury occurred, staff did not know the cause, and the DON did not report the injury of unknown source to CDPH within the required 2 hours despite the facility policy requiring prompt reporting.
Failure to Thoroughly Investigate an Injury of Unknown Origin: A resident with DM, bipolar disorder, schizophrenia, HTN, anemia, and cognitive impairment was found with a painful right forearm wound of unknown origin and sent to the GACH. Later, the resident could not explain how the injury occurred, and an LVN observed an open wound with exposed tissue plus a second wound with dried blood. The Admin said she did not investigate because she was not aware, while the DON said she interviewed staff but had no documentation and did not investigate further because she did not think another resident caused the injury.
Failure to report resident-to-resident altercation to CDPH. A resident with schizophrenia, anxiety, and depression was hit in the face and had coffee thrown at her by another resident with dementia and severely impaired cognition. Staff documented redness and severe pain, and although an abuse report was faxed to the Ombudsman and law enforcement was called, CDPH was not notified within the required 2-hour timeframe because of an oversight.
A resident with schizophrenia, anxiety, major depressive disorder, and severely impaired cognition was placed on 1:1 monitoring after becoming physically aggressive and striking other residents. During observation, the resident sat between two other residents while the assigned CNA was about 10 to nearly 12 feet away and looking at a phone, despite the facility’s 1:1 guidance calling for staff to stay within 3 to 5 feet.
A resident was readmitted with a generalized itchy rash documented on multiple skin checks as a new issue requiring tracking, but staff did not initiate a COC, notify the physician, monitor the condition, or provide treatment over several days. The rash was not discussed in the IDT care conference, and the facility’s transfer form to the GACH incorrectly indicated there were no skin issues, despite prior documentation of a widespread rash. At the hospital, the resident was found to have a generalized rash and was later placed on isolation for scabies. Interviews with the TN, IP nurse, and an RN confirmed that no COC was completed, no prophylactic or symptomatic treatment was provided, and the rash was not communicated to the hospital, contrary to facility policies on scabies prevention and change of condition.
Food Storage and Hand Hygiene Lapses: Surveyors found an expired can of cherry fruit filling in dry storage, undated cereal bowls, and undated applesauce, juice, and jelly in the reach-in refrigerator. An aide also handled dirty dishes and then clean dishes with the same gloves without washing hands, and the DSS stated this could lead to cross-contamination.
CNA fed a resident while standing and leaning over him instead of sitting during the meal. The resident had dysphagia, hemiplegia, aphasia, severely impaired cognition, and was dependent on staff for eating; the CNA stated sitting was the expected process to help the resident feel more comfortable, and an LVN said CNAs were to sit with residents during feeding so they would feel dignified, relaxed, and not rushed.
Beneficiary notices were not accurately completed for two residents. SNF ABNs for both residents listed the last day of Medicare Part A skilled coverage and the daily private-pay amount, but neither form showed which of the three payment/service options was selected. One resident had bipolar disorder, DM2, MDD, and anxiety with intact cognition but no capacity for medical decisions; the other had encephalopathy, COPD, bipolar disorder, and depression with fluctuating decision-making capacity. The BOM stated the options were explained, but the forms were left incomplete.
Failure to Obtain Ordered CBC and CMP Labs: A resident with encephalopathy, dysphagia, CKD, and B-12 anemia had CBC and CMP labs ordered, but the results could not be found in the chart or lab binder. An LVN stated the lab company should have been notified of the order and that no receipt or results were available showing the labs were drawn.
Failure to provide personal hygiene and grooming assistance: A resident with dementia, muscle weakness, and COPD who was partially dependent on staff for personal hygiene was observed with a large amount of facial hair on the chin and dirty, untrimmed fingernails. The resident stated she had not been shaved for a long time and wanted her nails clean and trimmed, while a CNA and RN both confirmed the resident did not look groomed and needed assistance with personal hygiene. The facility policy called for shaving, hair grooming, and nail care.
Incorrect Low Air Loss Mattress Setting: A resident with a stage 4 pressure ulcer, DM, dysphagia, and UTI was observed on a low air loss mattress set at 150 lbs even though the resident weighed 206 lbs. The TN confirmed the setting was incorrect and stated mattress settings were based on resident weight and intended to help prevent further skin breakdown.
Expired specimen collection supplies and unrelated items were found in the medication storage room, including an open bottle of baby oil, air freshener, a used face mask, a syringe, and multiple specimen bags mixed into drawers labeled for other supplies. The room also contained expired Aptima urine collection kits, expired vacutainers, and an expired urine specimen container. An LVN stated that baby oil should not be stored there, expired items cannot be used, and disorganized storage can delay care while staff search for needed items.
Failure to complete pharmacist-recommended lab work for a resident with dementia, muscle weakness, and COPD. The consultant pharmacist’s MRR recommended a CMP, CBC, and valproic level, but RN documentation showed the recommendations were not acknowledged and the labs were not drawn. The RN stated staff failed to carry out the recommendations and that the order request should have been placed to the physician.
An LVN failed to perform hand hygiene at the door of a room before touching medication cups while preparing meds at medication cart #1. The nurse did not cleanse hands with soap or an alcohol-based rub before starting the med pass, and later stated that cross contamination or serious illness could occur. The facility P&P required good hand hygiene, including washing hands thoroughly before beginning a medication pass.
Insufficient Bedroom Square Footage: The facility failed to provide at least 80 sq. ft. per resident in 31 of 34 resident bedrooms. During a tour, surveyors observed multiple 2- and 3-resident rooms where residents could move in and out and where beds, bedside tables, and care equipment fit in the space. The Admin confirmed the rooms were below the required square footage and stated there were no resident complaints or adverse effects on health and safety.
A resident with severe cognitive impairment and multiple psychiatric diagnoses repeatedly refused psychotropic medications, but the LVN only documented the refusals without completing a required change of condition (COC) assessment. The DON confirmed that no COC assessment was done, despite facility policy mandating such documentation and follow-up when a resident refuses medication.
A resident with severe cognitive impairment and multiple diagnoses, including schizoaffective disorder, bipolar disorder, and epilepsy, repeatedly refused prescribed medications. Despite facility policy requiring a care plan for medication refusals, staff interviews and record review confirmed that no such care plan was developed to address the resident's ongoing refusals.
The facility did not ensure timely administration of medications for three residents with complex medical and psychiatric conditions, resulting in multiple instances where medications were given significantly later than scheduled. Additionally, controlled drug count records for two medication carts were found to have missing nurse signatures at shift changes, indicating incomplete documentation and lapses in accountability.
A resident with multiple chronic conditions was transferred to a hospital for altered mental status and was cleared for return, but the facility repeatedly denied readmission, citing no available male beds, despite records showing bed availability. The resident remained hospitalized for an extended period due to the facility's actions, which were not in accordance with facility policy.
A resident with severe cognitive impairment and multiple diagnoses received several orders for lorazepam with changes in dosage, frequency, and administration route, but the facility did not obtain or document informed consent for these medication changes as required by policy. Staff interviews and record reviews confirmed the absence of necessary consents in the electronic medical record for the specified orders.
A resident with severe cognitive impairment and a history of anxiety and dementia was given a PRN lorazepam order for 30 days, exceeding the facility's 14-day policy limit, without documented provider justification or evidence of increased agitation. The extension was requested by an LVN rather than the psychiatric provider, and there was no supporting documentation for the prolonged use.
A resident with severe cognitive impairment and total dependence on staff experienced an unwitnessed fall resulting in a skin tear. Following the incident, staff did not complete a fall risk evaluation, post-fall evaluation, or convene an IDT meeting as required by facility policy. Nursing staff and the DON confirmed these assessments and reviews were not performed after the fall.
A resident who required moderate assistance for transfers was left without help by a CNA after requesting to be moved from a wheelchair to bed. The resident attempted the transfer alone, resulting in a fall, pain, and emotional distress. The facility did not follow the resident's care plan or its own neglect prevention policy, leading to the resident's injury and subsequent hospital admission for further evaluation, including a new diagnosis of generalized anxiety disorder.
A resident with schizophrenia and a history of aggressive behavior did not receive accurate assessment or individualized care planning, resulting in repeated disruptive incidents and a physical altercation with another resident. The MDS did not reflect the resident's behavioral history, and there was a period without a behavior care plan. Staff acknowledged that documentation and interventions were inadequate for the resident's needs.
A resident with complex medical and psychiatric needs was discharged to an unlicensed board and care facility that could not provide required services, without proper interdisciplinary discharge planning, communication, or verification of the receiving facility's capabilities. This led to a fall, hospitalization, multiple transfers, and elopement, as key steps such as medication reconciliation and hand-off reporting were not completed.
A resident with a high fall risk and multiple medical conditions experienced three falls within a short period. The facility did not conduct required IDT meetings after each fall, as outlined in its Fall Management Program policy, and failed to maintain accurate fall risk assessments. These failures resulted in the resident continuing to fall and placed the resident at risk for serious injury.
A facility failed to transcribe and document treatment orders for a resident's skin lesions, leading to a lack of appropriate care. The resident, with severe cognitive impairment and multiple diagnoses, had specific treatment orders for lesions on the forehead and right ocular region. However, these orders were not entered into the EMR or documented in the Treatment Administration Record, contrary to facility policy. Interviews with staff confirmed the absence of documentation, highlighting a risk of inadequate treatment and communication delays.
A resident with schizophrenia and anxiety disorder was hit in the face by another resident with schizophrenia and major depressive disorder, due to inadequate supervision. The facility's policy required a 1:1 sitter for the aggressive resident, but the sitter was not close enough to intervene. The Director of Nursing admitted the staff failed to provide appropriate supervision, leading to the incident.
A facility failed to monitor a resident's behaviors while on psychotropic medications, including Depakote, Invega Sustena, and Risperdal, prescribed for schizophrenia and major depressive disorder. The absence of documented behavior monitoring, as required by the facility's policy, was confirmed by the DON, highlighting a lapse in assessing medication effectiveness and managing psychiatric behaviors.
The facility was found deficient in food storage and handling practices, with rotten tomatoes in the refrigerator, lemonade stored near chemicals, and buildup in the coffee machine's sight glass tube. These issues, observed by the Dietary Supervisor, could lead to foodborne illnesses among residents.
A resident with multiple health conditions did not receive several prescribed medications over a period due to availability issues and storage errors in the medication cart. The facility's failure to administer medications as ordered led to significant medication errors, as observed in the MAR and confirmed by the DON and RN.
The facility failed to maintain cleanliness in medication storage, as sticky residue was found in the bottom drawer of a medication cart and around a Pro-Stat liquid bottle cap. An LVN confirmed the issue, which contradicts the facility's policy requiring clean and clutter-free medication storage areas.
The facility did not post the most recent CDPH survey results in accessible areas, violating residents' rights to examine these results. The Administrator admitted the latest survey from December 2023 was kept in her office, while the displayed binder contained outdated results from May 2021.
A facility failed to maintain a sanitary environment for a resident by not emptying the trash in a timely manner, leading to gnat production. The resident, with moderate cognitive impairment and independent in daily activities, was observed with an overflowing trash can and gnats present, posing an infection risk. The facility's policy mandates a safe, clean, and comfortable environment, which was not followed.
A facility failed to transmit a resident's discharge MDS assessment to CMS within the required 14 days, potentially affecting billing and data accuracy. The resident, with diagnoses including schizophrenia and COPD, was discharged to a hospital, but the MDS was transmitted late. The MDSN confirmed the delay, and the DON noted potential impacts on reimbursement and staffing.
A facility failed to complete a PASARR Level II evaluation for a resident with schizophrenia and other conditions, due to the resident's unavailability for assessment. The MDSN admitted that the staff should have resubmitted the Level I evaluation to ensure the resident's mental health needs were met, as per the facility's policy.
A resident with dementia, dysphagia, and severe protein-calorie malnutrition experienced significant weight loss, losing 5.2% of their body weight in one week and 6.9% in one month. Despite these changes, the facility did not develop a care plan to address the resident's nutritional needs, as acknowledged by the Dietary Service Supervisor. The resident required supervision for eating and other activities, and the facility's policy emphasizes updating care plans based on assessed needs, which was not done in this case.
A facility failed to consistently monitor a resident's weight, despite the resident being on an appetite stimulant and having conditions like Type 2 DM and malnutrition. The resident's weight was last recorded in July, contrary to the facility's policy requiring monthly evaluations. This oversight could delay necessary interventions for the resident's health conditions.
A resident reported missing prescription eyeglasses, but the facility failed to arrange an optometry consult despite an existing order for eye health and vision consult. The resident, with conditions like parkinsonism and schizophrenia, experienced difficulty seeing without the glasses. The Social Service Director acknowledged the oversight, and the facility's policy on referrals was not followed, impacting the resident's quality of life.
A resident with a high risk of falls did not have a low bed or bilateral floor mats as ordered by a physician, despite being at risk due to confusion and balance issues. The facility's policies on fall management and resident safety were not followed, placing the resident at risk for injury.
A facility failed to document the arm circumference and external catheter length for a resident with a midline catheter, as required by their policy. Despite the resident's conditions, including diabetes and a pressure ulcer, there was no record of these measurements over a month-long period. Interviews with staff confirmed the lack of documentation, highlighting a failure to adhere to established procedures.
A resident with emphysema and other conditions was not properly monitored for oxygen saturation levels as ordered by a physician. Despite an order for oxygen at 2 liters to maintain saturation above 92%, the facility failed to consistently check the resident's oxygen levels, with significant gaps in monitoring. An LVN acknowledged the oversight, noting that the resident might have needed oxygen without staff being aware.
The facility failed to post updated daily nurse staffing information, with the last update dated several weeks prior. The Director of Staff Development, new to the role, acknowledged the oversight and the importance of including both projected and actual hours worked by licensed nurses and CNAs, as well as the resident census. This failure violated resident rights by not providing timely access to staffing information.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its Abuse Prevention and Management policy by not reporting an injury of unknown origin to CDPH Licensing and Certification within two hours for a resident who sustained nasal fractures, a frontal scalp hematoma, and a laceration to the left eyebrow. The policy stated that the Administrator or designated representative would send a written report to CDPH within two hours when an injury of unknown source met the policy criteria. The report identified one sampled resident affected by this deficiency. The resident had multiple diagnoses including COPD, dysphagia, difficulty walking, muscle weakness, schizophrenia, dementia, and depression. The resident's MDS indicated moderate cognitive impairment and dependence on staff for several activities of daily living, including bed mobility, transfers, and personal hygiene. On the evening of the incident, staff found the resident sitting on the bed with blood on the face, bed, clothes, and floor, and the resident had an actively bleeding laceration to the left eye area. The resident was taken to the hospital, where CT imaging showed acute comminuted fractures of the right and left nasal bones, a left frontal scalp hematoma with soft tissue laceration, and repair of a two-centimeter left eyebrow laceration with sutures. Staff interviews showed that no one witnessed how the injury occurred. An LVN stated there were no staff present in the room and the roommates were asleep when the resident was found. An RN stated the resident could not explain what happened. The DON stated the injuries should have been reported within two hours because no one saw the resident fall, staff did not find the resident on the floor, and the resident could not verbalize the cause of the injuries. The ADM stated she was notified the next day and the incident was not reported within two hours because staff assumed the injuries were due to a fall, although no staff witnessed a fall.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who had moderate cognitive impairment and diagnoses including COPD, dysphagia, difficulty walking, muscle weakness, schizophrenia, dementia, and depression. The resident was dependent on staff for bed mobility, transfers, and personal hygiene. On 6/9/2026, the resident was found with a large amount of blood on his person and surrounding area, and he had an actively bleeding laceration to the left eye area. Pressure was applied and he was sent to the GACH. A CT of the head and maxillofacial area on 6/10/2026 showed acute comminuted fractures of the distal tip of the right and left nasal bones with soft tissue swelling, as well as a left frontal scalp hematoma with soft tissue laceration. The GACH reexamination note documented repair of a 2 cm laceration of the left eyebrow with 5 sutures placed. LVN 2 stated he arrived for his shift at approximately 11:00 p.m. on 6/9/2026 and found the resident sitting on his bed with blood on his face, bed, clothes, and the floor. LVN 2 did not witness how the injury occurred, and the resident could not explain it. The DON stated no one saw the resident fall and the resident could not verbalize the cause of the injuries. The DON also stated she did not interview other residents, including the resident’s roommates, or staff who worked the evening shift on 6/9/2026 regarding the incident, and she did not further investigate because she had no reason to question whether another resident or staff caused the injuries. LVN 2 and CNA 1 both stated they were not interviewed as part of an investigation of the incident. The facility’s policy required unexplained injuries to be promptly and thoroughly investigated, and its abuse prevention policy stated the administrator or designee would initiate an immediate investigation and interview individuals who may have information relevant to the allegation.
Failure to Maintain Ordered 1:1 Monitoring
Penalty
Summary
The facility failed to implement Resident 1’s care plan for ongoing 1:1 monitoring related to unsafe behaviors and impaired safety awareness. Resident 1’s diagnoses included COPD, dysphagia, difficulty walking, muscle weakness, schizophrenia, dementia, and depression. The MDS dated 8/27/2025 indicated moderate cognitive impairment and dependence on staff for multiple activities of daily living, including bed mobility, transfers, and personal hygiene. The care plan dated 5/6/2026 identified the resident as at risk for unsafe behaviors and impaired safety awareness related to schizophrenia, cognitive impairment, akathisia, and behavioral disturbances, and it indicated ongoing need for 1:1 monitoring for safety. On 6/9/2026, Resident 1 was found with a large amount of blood on his person and surrounding area, and had a laceration to the left eye area that was actively bleeding. Pressure was applied and the resident was transferred to a GACH for evaluation and treatment. LVN 2 stated that when he arrived for his shift at approximately 11:00 p.m., he saw Resident 1 sitting on his bed with blood on his face, bed, clothes, and the floor. LVN 2 stated he did not witness how the injury occurred, the resident could not explain it, there were no staff present in the room, and the roommates were asleep. CNA 1 stated she was assigned as the resident’s 1:1 hourly sitter from 10:30 p.m. to 11:00 p.m. and last saw him at 10:45 p.m. when she changed his shorts, then left the room and did not return before reporting off duty at 11:00 p.m. The DON stated the resident had a 1:1 sitter on the day shift, but the assignment was changed to a 1:1 hourly sitter for the 3:00 p.m. to 11:00 p.m. shift. The DON also stated a 1:1 sitter was expected to stay with the resident the entire shift, while an hourly sitter was only expected to check every 10 to 15 minutes, and there was no documentation to indicate 1:1 monitoring was provided. The facility policy on resident safety stated the interdisciplinary care team would establish person-centered observation or monitoring systems, and checks would be made at least every two hours, with more frequent checks as needed.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the physician of a resident's refusal to take scheduled medications for one of four sampled residents. Resident 2 was admitted with diagnoses including bipolar disorder, atrial fibrillation, and hypertension. The resident's MDS dated 5/30/2026 indicated moderately impaired cognitive skills for daily decision making and the need for moderate assistance with toileting hygiene, lower body dressing, and personal hygiene. The H&P dated 5/27/2026 stated the resident did not have the capacity to consent. Physician orders dated 5/23/2026 included Depakote 250 mg twice daily, Eliquis 5 mg twice daily, Losartan Potassium 25 mg daily, and Risperdal 1 mg twice daily. The MAR from 5/24/2026 to 5/27/2026 showed the resident refused Depakote, Eliquis, Losartan, and Risperdal. Review of the progress notes did not show that the physician was notified of these refusals on 5/24/2026, 5/25/2026, 5/26/2026, or 5/27/2026. LVN 4 stated the standard of practice was to notify the physician after three consecutive medication refusals and that refusal of medication was considered a change in condition. The DON stated notifying the physician when a resident refused medication was essential for resident safety and for the physician to offer an alternative treatment plan. Facility policies stated the attending physician or prescribing provider would be notified of refusal of treatment or medication and the refusal documented in the medical record.
Failure to Develop Person-Centered Care Plan for Ear Pain
Penalty
Summary
Facility staff failed to develop a person-centered comprehensive care plan for Resident 1's right ear pain. Resident 1 was initially admitted and later readmitted to the facility, and had diagnoses including schizophrenia, COPD, and DM. The H&P dated 2/14/2026 indicated Resident 1 had fluctuating capacity to understand and make decisions. The MDS dated 4/10/2026 indicated Resident 1's cognitive skills for daily decision making were moderately impaired and that the resident required substantial assistance with toileting hygiene and upper and lower body dressing. The Change in Condition Evaluation dated 5/24/2026 documented that Resident 1 had right ear pain. During the 6/10/2026 interview and record review, LVN 4 reviewed the care plans and stated there was no specific comprehensive care plan developed to address the resident's complaint of right ear pain. LVN 4 stated care plans should be individualized and pertain to each resident's care, and that the purpose of the care plan was continuity of care. The DON stated a care plan was very important to address residents' areas of concern and show the facility's plan of action. The facility policy titled Comprehensive Person-Centered Care Planning stated the comprehensive care plan would be reviewed and revised if there is an onset of new problems and a change of condition.
Failure to Monitor Behaviors for Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to monitor the behaviors of two residents who were prescribed psychotropic medications. One resident had diagnoses including schizophrenia, COPD, and DM, and the H&P noted fluctuating capacity to understand and make decisions. The MDS showed moderately impaired cognitive skills for daily decision making and substantial assistance needs with toileting hygiene and dressing. The physician ordered Divalproex Sodium 500 mg three times daily for schizophrenia manifested by striking out and Seroquel 200 mg twice daily for schizophrenia manifested by verbal aggression and outburst of anger. During review of the MAR from 2/14/2026 through 6/3/2026, there was no documented behavior monitoring for striking out, aggression, or angry outbursts, and LVN 4 stated nurses should monitor the behavior by placing a hashmark and documenting the number of episodes on the MAR. A second resident had diagnoses including ADHD, MDD, and anxiety disorder, and the H&P also noted fluctuating capacity to understand and make decisions. The physician ordered Bupropion Hydrochloride Extended Release one tablet twice daily for depression manifested by self-isolation. During review of the MAR from 5/30/2026 through 6/9/2026 with the DON, there was no documented behavior monitoring for self-isolation. The DON stated it was important to tally and document the resident's behavior to evaluate continued use and dose adjustment of psychotropic medications. The facility policy titled Behavior and Psychoactive Medication Management stated that any order for psychoactive medications must include a specific behavior manifestation, but it did not disclose the frequency and importance of monitoring resident behavior.
Failure to Protect Resident Dignity During Hallway Ambulation
Penalty
Summary
The facility failed to protect the dignity of one resident when the resident was observed walking in the hallway wearing a diaper without pants. The resident had diagnoses including schizoaffective disorder, dementia with behavioral disturbance, and acute cystitis without hematuria. The resident’s H&P noted fluctuating capacity, and the MDS indicated severely impaired cognition, frequent urinary incontinence, and the need for staff assistance with toileting hygiene and lower body dressing. During a concurrent observation and interview, a CNA escorted the resident in the hallway in a diaper while the resident wanted to smoke a cigarette. The CNA stated the resident often walked in the hallway while in a diaper and acknowledged that this could be embarrassing for the resident. The DON later stated the resident’s dignity was not being respected and was exposed. The facility policy on Resident Rights-Quality of Life stated residents would be cared for with dignity and respect and encouraged and assisted to dress in their own clothes rather than hospital gowns.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to follow its Abuse-Reporting and Investigations policy when it did not report an injury of unknown source to CDPH within two hours after a resident was found with a wound to the right forearm. The resident had diagnoses including type 2 DM, bipolar disorder, schizophrenia, HTN, anemia, and cognitive impairment. The resident was dependent for dressing, personal hygiene, showering, and transfers. On 4/30/2026 at 12:30 a.m., the resident was found with an injury of unknown origin and complained of pain rated 10 out of 10. EMS was activated, and the resident was transferred by ambulance to the GACH. During later observation, the resident was seen with gauze wrapped around the forearm, and when the gauze was removed, there was a quarter-sized open wound with exposed pink and red tissue and another wound with exposed reddened skin and dried blood measuring approximately 2 inches by 1 inch. The resident stated she did not know what happened to her arm and could not recall whether anyone had injured it. Staff also stated they did not know how the resident acquired the wound. The DON stated the incident should have been reported to the State Agency within two hours of the facility being made aware of it, but it was not reported because she did not know how it occurred. RN 1 stated an unidentified CNA informed him of the injury, the resident could not explain how it happened, and he reported it to the DON and the physician.
Failure to Thoroughly Investigate an Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was found with a wound to the right forearm. The resident had diagnoses including type 2 DM, bipolar disorder, schizophrenia, hypertension, and anemia, and the H&P documented cognitive impairment. The MDS indicated the resident was dependent for dressing, personal hygiene, showering, and transfers in and out of bed. On 4/30/2026, a progress note documented that the resident was found with an injury of unknown origin and complained of pain rated 10 out of 10, after which EMS was activated and the resident was transferred by ambulance to the GACH. On 5/4/2026, the resident was observed with gauze wrapped around the forearm and stated she did not know what happened to her arm and could not recall whether anyone had injured it. When the gauze was removed, an LVN observed a quarter-sized open wound with exposed pink and red tissue and another wound with exposed reddened skin and dried blood measuring approximately 2 inches by 1 inch. The LVN stated staff did not know how the resident acquired the wound. The Administrator stated she did not investigate because she was not made aware until 5/4/2026, while the DON stated she had been notified on 4/30/2026 that the resident was sent to the GACH for a wound of unknown origin. The DON stated she interviewed nurses and CNAs but could not provide names or documentation of the investigation, and she did not investigate further because she did not think another resident caused the injury.
Failure to Report Resident-to-Resident Altercation to CDPH
Penalty
Summary
The facility failed to ensure an altercation between two residents was reported to CDPH within two hours after one resident hit the other and threw coffee in her face. Resident 3 had diagnoses including schizophrenia, anxiety, and depression, and her H&P indicated she had the capacity to understand and make decisions; her MDS indicated intact cognition and that she required partial/moderate assistance with toileting hygiene, showering, and dressing. After the incident, Resident 3 reported that Resident 4 threw a cup of coffee at her and hit her in the face, and staff documented slight redness to her chin and cheeks along with pain rated 10 out of 10. Resident 4 had diagnoses including dementia, anxiety, and metabolic encephalopathy, and her MDS indicated severely impaired cognition and the need for supervision with toileting hygiene, showering, and dressing. RN 1 stated she completed an abuse reporting form and faxed it to the Ombudsman within two hours, but did not receive confirmation that CDPH received the report. The Administrator later confirmed that the abuse reporting form had been faxed to the local Ombudsman and law enforcement was called, but CDPH was not notified because of an accidental oversight, and the facility acknowledged CDPH should have been notified within two hours of the altercation.
Failure to Maintain Required 1:1 Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident placed on one-to-one monitoring after becoming physically aggressive and striking other residents. The resident had diagnoses including schizophrenia, anxiety, and major depressive disorder, and records showed severely impaired cognition with a potential for hallucinations. The resident’s change of condition documented the aggressive behavior and placement on one-to-one supervision, and the care plan and physician orders called for close visual monitoring and a sitter for visual monitoring related to resident-to-resident altercation. During observation on the outside patio, the resident was seated between two other residents and was within arm’s reach of them while the assigned CNA was approximately 10 to nearly 12 feet away and seated in a chair looking at a phone. The CNA stated he was the resident’s assigned one-to-one sitter but remained away from the resident because he wanted to keep his distance from cigarette smoke. Staff and the administrator confirmed the CNA was too far away, and the facility’s lesson plan for one-to-one supervision stated staff were to maintain a safe distance of three to five feet.
Failure to Assess, Treat, and Communicate Generalized Rash Leading to Scabies Diagnosis
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to recognize and respond to a change of condition related to a resident’s generalized itchy rash, to provide treatment, and to communicate this condition to the receiving hospital. The resident, who had diagnoses including schizophrenia, cardiomegaly, and chronic kidney disease and whose H&P noted fluctuating capacity to understand and make decisions, was readmitted to the facility with generalized itchy rashes over the whole body. A progress note dated 1/10/2026 documented the readmission with generalized itchy rashes, and a skin check on the same date recorded a rash on the abdomen, cervical region, and bilateral front and back thighs, marked as a new issue to be tracked. Despite this documentation, no Change of Condition (COC) form was initiated, and the physician was not notified as required by facility policy. Subsequent documentation and interviews showed that the rash continued without appropriate assessment or treatment. A multidisciplinary care conference (IDT) dated 1/13/2026 contained no indication of the rash or any medical treatment for the generalized itching. A follow-up skin check dated 1/15/2026 again documented the rash in the same areas and indicated it should be tracked and reviewed, yet the resident was not monitored for the rash between 1/11/2026 and 1/15/2026, and no treatment was initiated. The Treatment Nurse stated that the situation represented a COC and that the physician should have been notified so medical treatment could be started, and also acknowledged that staff would not know if the rash was improving or worsening due to lack of monitoring. The Infection Preventionist similarly stated that the resident should have been treated prophylactically and that there was no COC, no monitoring for symptoms, and no treatment for itching. When the resident was transferred to a General Acute Care Hospital on 1/15/2026, the facility’s discharge summary (SNF/NF to Hospital Transfer Form) indicated that the resident had no skin issues, despite prior documentation of a generalized rash. Hospital records from the same date documented a generalized rash over the whole body, and by 1/17/2026 the hospital had placed the resident on isolation precautions for scabies. The Treatment Nurse and a Registered Nurse both stated that licensed staff were expected to provide a complete report to the hospital, including skin conditions, and acknowledged that the rash was not communicated, characterizing this as poor communication. Facility policies on Prevention and Management of Scabies required examination for signs and symptoms of scabies on admission, isolation of undiagnosed and untreated rashes, and notification of the DON for suspicious rashes, while the Change of Conditions policy required physician notification, assessment, SBAR communication, and documentation every 72 hours for significant changes. These policy requirements were not followed in the resident’s case.
Food Storage and Hand Hygiene Lapses
Penalty
Summary
The facility failed to ensure that food in dry storage and the reach-in refrigerator was properly dated and handled. During observation in the dry storage room, surveyors found one large can of expired cherry fruit filling and four cereal bowls that were not dated. In the reach-in refrigerator, containers of applesauce, juice, and jelly were also found without a use-by date. The Dietary Services Supervisor stated the expired can should have been disposed of, the cereal bowls should have been thrown away so they would not be used again, and the undated refrigerated items lacked a use-by date needed so staff would know when to discard them. The facility also failed to ensure proper hand hygiene and glove use during dish handling. During observation, Dietary Aide 1 touched dirty dishes and then touched clean dishes without removing gloves or washing hands. The Dietary Services Supervisor stated that one staff member was responsible for washing dirty dishes and another for clean dishes, and that the aide was to remove gloves and wash hands after handling dirty dishes to prevent cross-contamination. The facility policy titled Food Storage and Handling required opened products to be labeled and dated, and the Dietary Department-Infection Control policy required proper hand washing after handling soiled equipment or utensils and before engaging with clean equipment and utensils.
CNA Fed Resident While Standing Instead of Sitting
Penalty
Summary
The facility failed to ensure that CNA 1 was seated while feeding Resident 82. During an observation on 1/6/2026 at 12:49 p.m., CNA 1 was feeding Resident 82 while standing. In a concurrent observation and interview at 12:52 p.m. in Resident 82's room, CNA 1 was still feeding while standing and leaning over the resident. CNA 1 stated the process was to sit with Resident 82 during feedings and said sitting was done to make him feel more comfortable while eating. Resident 82's record showed diagnoses of dysphagia, hemiplegia, and aphasia. The admission Face Sheet showed the resident was initially admitted and later readmitted to the facility. The MDS dated 10/24/2025 indicated Resident 82's cognition was severely impaired and that he was dependent on staff for eating, showering, and dressing. Physician orders dated 12/10/2025 indicated the resident was incapable of making healthcare decisions, and orders dated 12/18/2025 indicated a controlled carbohydrate diet. During interview on 1/7/2026, LVN 3 stated CNAs were to sit with residents during feeding so the resident would feel dignified while eating, feel more relaxed, not feel intimidated, and not feel rushed to eat.
Beneficiary Notices Not Fully Completed for Two Residents
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. The facility failed to ensure beneficiary notices were accurately completed for two sampled residents, Resident 21 and Resident 109. For Resident 21, the record showed diagnoses including bipolar disorder, type 2 diabetes, major depressive disorder, and anxiety. The SNF ABN identified the last day of Medicare Part A skilled services coverage and stated the resident would be responsible for $376.00 per day for continued care, but it did not indicate which of the three service options the resident chose. The MDS indicated the resident was cognitively intact and required supervision with ADLs, and the H&P stated the resident did not have the capacity to make medical decisions but could make needs known. For Resident 109, the record showed diagnoses including encephalopathy, COPD, bipolar disorder, and depression. The H&P indicated fluctuating capacity to understand and make decisions, while the MDS indicated the resident was cognitively intact and required substantial assistance with ADLs. The SNF ABN also identified the last day of Medicare Part A skilled services coverage and stated the resident would owe $376.00 per day for continued care, but it did not show which of the three service options the resident selected. During interview, the Business Office Manager stated the SNF ABN should be issued 3 days before the last Medicare Part A coverage day and that the options were explained to both residents, but the service options were not checked. The facility policy titled Beneficiary Notice Initiative stated the purpose of the notice was to determine and inform Medicare beneficiaries of coverage decisions in accordance with Medicare guidelines.
Failure to Obtain Ordered CBC and CMP Labs
Penalty
Summary
The facility failed to ensure that CBC and CMP labs were obtained for one resident with diagnoses including encephalopathy, dysphagia, chronic kidney disease, and vitamin B-12 anemia. The resident’s MDS dated 10/23/2025 indicated severely impaired cognitive skills and dependence on staff for ADLs, and the H&P dated 1/4/2026 stated the resident did not have the capacity to make decisions. A physician’s order dated 11/21/2025 directed CBC and CMP testing, but on 1/7/2026 the resident’s CBC and CMP results could not be located in the medical chart or the facility’s laboratory services binder. During a concurrent interview and record review on 01/07/2026, LVN 1 stated the protocol for physician orders was to note and carry them out for all residents, and that a licensed nurse was required to notify the facility’s lab company of new lab orders. LVN 1 stated the lab company would then come to the facility, review the orders, draw the labs, and provide a receipt for each resident seen. LVN 1 stated she did not see a receipt for CBC and CMP labs or results showing the labs were drawn for the resident. The facility’s Laboratory Services policy stated that upon receiving the order, the licensed nurse would notify the laboratory of the orders, and the Physician Orders policy stated lab orders would include the name of the test, frequency, reason, and associated diagnosis.
Failure to Provide Personal Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to ensure that Resident 2 received personal hygiene assistance for grooming, including shaving and nail care. Resident 2 was admitted and later readmitted with diagnoses including dementia, muscle weakness, and COPD. The H&P documented cognitive impairment, and the MDS indicated moderately impaired cognition with partial/moderate dependence on staff for personal hygiene, showering, and dressing. During observation and interview, Resident 2 was found with a large amount of facial hair on the chin and dirty, untrimmed fingernails. Resident 2 stated she had not been shaved on her chin for a long time, did not want hair on her chin, and wanted her nails clean and trimmed, saying it was embarrassing not to have her face and nails looking clean. CNA 2 and RN 1 both observed that Resident 2 did not look groomed, had facial hair and dirty, untrimmed nails, and stated she needed assistance with personal hygiene. The facility policy on grooming indicated residents would be assisted with shaving, hair grooming, and nail care.
Incorrect Low Air Loss Mattress Setting
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to ensure the low air loss mattress setting was correct for one resident with a stage 4 pressure ulcer. The resident’s face sheet showed diagnoses including a stage 4 pressure ulcer, dysphagia, type 2 DM, and UTI. The H&P dated 10/1/2025 indicated the resident had the capacity to understand and make decisions, and the MDS dated 10/15/2025 indicated the resident was cognitively intact and dependent on staff for ADLs. During an observation on 1/6/2025 at 10:13 a.m., the resident was lying in bed on a low air loss mattress set at 150 lbs. A record review later showed the resident weighed 206 lbs. During a concurrent observation and interview on 1/8/2026, the TN observed and stated the mattress was still set to 150 lbs. The TN stated low air loss mattress settings were based on resident weight, that the mattress was intended to prevent further skin breakdown in residents with pressure ulcers, and that the resident’s setting was incorrect. The facility policy stated mattresses were to provide pressure reduction to residents at risk for skin breakdown and distribute body weight to relieve pressure.
Expired Specimen Supplies and Cluttered Medication Storage Room
Penalty
Summary
The facility failed to properly remove expired items and failed to organize stored items in the medication storage room. During observation, an open bottle of baby oil was found in the far-right upper cabinet, along with two containers of air freshener, a used face mask, one BD Safety Glide 1 mL syringe, and multiple specimen bags in a drawer labeled for elastic bandage rolls. The same area also contained two expired Aptima urine specimen collection kits, six expired 4 mL vacutainers, and one expired HOLOGIC Aptima 2cc urine specimen container. During interview, LVN2 stated that baby oil is not medication and should not be in the medication storage room, that expired items cannot be used because they could produce incorrect results if used beyond the expiration date, and that disorganized storage would take longer when providing care. The facility policy stated that medication and biologicals are to be stored safely, securely, and properly, following manufacturer or supplier recommendations, and that medication storage areas are to be kept clean, well-lit, and free of clutter.
Failure to Complete Pharmacist-Recommended Lab Work
Penalty
Summary
The facility failed to ensure that laboratory recommendations from the consultant pharmacist’s Medication Regimen Review were completed for one sampled resident. The resident had diagnoses of dementia, muscle weakness, and COPD, and the record also noted cognitive impairment and moderate impairment in cognition on the MDS, with partial/moderate dependence on staff for personal hygiene, showering, and dressing. The consultant pharmacist’s MRR dated 12/27/2025 recommended obtaining a CMP, CBC, and valproic level. During a concurrent interview and record review on 1/8/2026, the RN stated there was no documentation that the MRR recommendations were acknowledged and that the laboratory work was not drawn. The RN stated that when laboratory recommendations were in place, an order request should have been placed to the physician, and that the recommendation should take no more than three days to complete. The RN also stated staff failed to carry out the recommendations, and that this could have potentially affected the resident’s medication regimen and caused a delay in care. The facility policy stated that MRR recommendations are acted upon and documented by facility staff.
Failure to Perform Hand Hygiene During Medication Preparation
Penalty
Summary
Licensed Nurse 1 failed to perform hand hygiene at the door of room [ROOM NUMBER] before touching medication cups while preparing medications for administration at medication cart #1. During the observation, the nurse did not cleanse hands with soap or an alcohol-based rub before beginning the medication pass. When interviewed, LVN1 stated that cross contamination could occur or a serious illness could be spread to someone. Review of the facility’s Preparation and General Guidelines IIA2: Medication Administration-General Guidelines Policy & Procedure, dated May 2022, showed that the person administering medications is to adhere to good hand hygiene, including washing hands thoroughly before beginning a medication pass.
Insufficient Bedroom Square Footage
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 31 of 34 resident bedrooms. During a facility tour on 1/6/2025 at 8:34 a.m., rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, and 35 were observed, and residents were able to move in and out of their rooms. It was also observed that there was enough space for the residents' beds, bedside tables, and resident care equipment. A review of the facility's waiver request for bedrooms to measure at least 80 sq. ft. per resident, dated 10/1/2025, showed the Administrator submitted a waiver request for 31 of the 34 resident rooms. The waiver request stated that granting the waiver would not adversely affect residents' health and safety and was in accordance with the special needs of the residents at the facility. The rooms identified as below the required square footage included multiple 2- and 3-resident rooms, with measurements listed as low as 221.6 sq. ft. for 3 residents and 221.6 to 224.2 sq. ft. for 2 residents. During an interview on 1/8/2025 at 2:01 p.m., the Administrator confirmed the rooms were less than the required 80 sq. ft. per resident and stated there had been no resident complaints and no adverse effect on health and safety.
Failure to Document Change of Condition Assessment After Medication Refusal
Penalty
Summary
The facility failed to document a change of condition (COC) assessment for a resident who refused psychotropic medications. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and epilepsy, was noted to have severe cognitive impairment and required assistance with activities of daily living. Despite the resident's repeated refusal of medications on multiple occasions, the licensed vocational nurse (LVN) only documented the refusal but did not complete a COC assessment as required by facility policy. The LVN acknowledged that medication refusal constituted a change in condition and should have been documented accordingly. Interviews with the resident confirmed ongoing refusal of medications, and the Director of Nursing (DON) verified that no COC assessment was completed in response to these refusals. Facility policy required licensed nurses to assess changes in condition, determine appropriate interventions, and notify the resident's physician and legal representative or family member in the event of untoward responses to medications. The lack of a documented COC assessment meant that the resident's current condition and behavior were not properly monitored as per policy.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who consistently refused to take prescribed medications. During observation and interviews, the resident was noted to refuse medications, stating they did not need them, despite having diagnoses including schizoaffective disorder, bipolar disorder, and epilepsy. The resident's medical records indicated severe cognitive impairment and a need for supervision or assistance with activities of daily living. Physician orders documented multiple medications for mental health and seizure management, but there was no care plan addressing the resident's medication refusals. Staff interviews confirmed that the resident routinely refused medications and that facility policy required a care plan to be developed in such cases. The LVN and DON both acknowledged that a care plan should have been created to address the refusals, and the facility's policy specified that care plans must be updated based on assessed needs. Despite these requirements, no care plan was in place to guide staff in managing the resident's medication refusals.
Medication Administration Delays and Incomplete Narcotic Count Records
Penalty
Summary
The facility failed to ensure timely administration of medications for three of six sampled residents. For one resident with schizoaffective disorder, major depressive disorder, and hypertension, medications such as lithium carbonate, lisinopril, risperdal, and gabapentin were not administered at the scheduled times, with documentation showing administration occurred significantly later than ordered. Another resident with schizophrenia, type 2 diabetes, and hypertension also experienced delays in receiving medications including empagliflozin, metformin, lisinopril, and risperdal, with records indicating these medications were given well after the scheduled times on multiple days. A third resident with schizoaffective disorder, epilepsy, and dementia had similar delays in receiving levetiracetam, memantine, haloperidol, and divalproex sodium, as shown by medication administration records and audit reports. Interviews with licensed vocational nurses confirmed that medications were administered more than one hour after the scheduled times, which was acknowledged as contrary to facility protocol and physician orders. The nurses stated that medications should be given within one hour before or after the scheduled time, and that delays occurred when residents initially refused medications or due to other factors. The actual times of administration were not always accurately documented, and staff recognized that such delays could affect residents' moods and symptoms. Additionally, the facility failed to maintain complete and accurate controlled drug count records for two of three medication carts. Reviews of the narcotic count sheets revealed multiple blank, unsigned spaces where licensed nurses had not signed at shift changes, as required by facility policy. Interviews with nursing staff confirmed that the count sheets should be signed at every change of shift after narcotics are counted, and that missing signatures indicated a lapse in accountability for controlled substances.
Failure to Readmit Resident Despite Bed Availability
Penalty
Summary
A deficiency occurred when a resident with diagnoses including liver cirrhosis, COPD, and bipolar disorder was transferred to a general acute care hospital (GACH) for altered mental status. The resident was cleared for return to the facility by the hospital, but the facility repeatedly denied readmission, citing a lack of available male beds. However, facility records indicated that a male bed was available on several dates during the period in question. The facility's Admission Director (AD) acknowledged receiving multiple inquiries from the hospital's discharge planner regarding bed availability and confirmed that the resident was denied readmission by the Administrator (ADM) without a clear reason. The Director of Nursing (DON) stated that the facility could meet the resident's needs and that there was no justification for denying readmission, even after the expiration of the seven-day bed hold period. The resident remained in the hospital for 14 days beyond the initial discharge date due to the facility's refusal to readmit. A review of facility policies indicated that residents previously admitted to the facility should be readmitted when eligible, and that Medi-Cal/Medicaid eligible residents should be readmitted to their previous room or the first available bed in a semi-private room if hospitalized for more than seven days. Despite these policies and available beds, the facility did not readmit the resident, resulting in a prolonged hospital stay.
Failure to Obtain and Document Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the use of psychotropic medications for one resident with diagnoses including cognitive communication deficit, anxiety, and dementia. The resident had severely impaired cognition and was dependent on staff for all activities of daily living. Multiple physician orders for lorazepam, an anti-anxiety medication, were issued with varying dosages, frequencies, and routes of administration over several months. However, there was no documented informed consent for several of these orders, specifically for those dated 6/15/2025 to 6/16/2025 and 7/13/2025 to 7/21/2025, as confirmed by the Medical Records Director. The only informed consent obtained in 2025 was for a later order starting 7/22/2025. Interviews with facility staff, including the Medical Records Director and the Director of Nursing, confirmed that informed consents should be stored in the electronic medical record and that new consents are required when there is a change in the frequency or route of psychotropic medication administration. Facility policy also requires written informed consent for psychotropic medications, to be renewed every six months and placed in the resident's medical record. Despite these policies, the required consents were not present for the specified medication orders, resulting in a failure to ensure the resident or their responsible party was informed about the medication's use and potential adverse effects.
PRN Psychoactive Medication Order Exceeded Policy Limit Without Provider Justification
Penalty
Summary
The facility failed to ensure that an as-needed (PRN) psychoactive medication order for a resident did not exceed the facility's policy limit of 14 days. The resident, who had diagnoses including cognitive communication deficit, anxiety, and dementia with severely impaired cognition and total dependence on staff for activities of daily living, was initially prescribed lorazepam for agitation for 14 days. After the initial order was discontinued, a new order was placed for lorazepam every 6 hours PRN for 30 days, despite the absence of documented behaviors indicating agitation at the time of the new order and no documented rationale from the prescribing provider for exceeding the 14-day limit. Review of the resident's records showed that the extension to 30 days was requested by an LVN, not the psychiatric provider, and there was no documentation from the provider supporting the need for prolonged administration. The facility's policy required that any PRN psychoactive medication order not exceed 14 days unless the physician documented a reason for continued use. Interviews with staff confirmed that the extension was not justified by an increase in the resident's agitation or by provider documentation, and that it was outside the LVN's scope to request such an extension.
Failure to Complete Required Post-Fall Evaluations and IDT Review
Penalty
Summary
The facility failed to conduct an Interdisciplinary Team (IDT) meeting, a fall risk evaluation, and a post-fall evaluation for a resident following an unwitnessed fall. The resident, who had diagnoses including cognitive communication deficit, anxiety, and dementia, was noted to have severely impaired cognition and was dependent on staff for all activities of daily living. After the resident experienced an unwitnessed fall and sustained a skin tear, staff did not complete the required fall risk evaluation or post-fall evaluation, nor did they convene an IDT meeting as outlined in facility policy. Interviews with nursing staff and the Director of Nursing confirmed that the necessary assessments and team review were not performed after the fall. The facility's policy required a new fall risk evaluation, a post-fall evaluation, and an IDT review with documentation following any fall. The absence of these actions was acknowledged by staff and leadership, and it was noted that these steps are intended to identify risk factors and update the care plan to prevent further incidents.
Failure to Provide Required Transfer Assistance Resulting in Resident Fall and Neglect
Penalty
Summary
A resident with hemiplegia and hemiparesis affecting the left side, who required moderate assistance for transfers and was dependent on staff for activities of daily living, was not provided the necessary care and services as outlined in their comprehensive assessment and care plan. On one occasion, the resident called for a CNA to assist with transferring from a wheelchair to bed. The CNA instructed the resident to get out of the chair and do it himself, then left the room without providing assistance. The resident, unable to safely transfer independently, attempted the transfer alone and subsequently fell from the wheelchair. The facility failed to implement the resident's At Risk for Falls Care Plan, which required staff to anticipate and meet the resident's needs, ensure the call light was within reach, and encourage its use for assistance. The care plan did not specify interventions for transfer assistance, despite the resident's documented need for moderate help. Additionally, the facility did not follow its own Abuse - Prevention, Screening, & Training Program policy, which defines neglect as the failure to provide necessary goods and services to maintain a resident's well-being and avoid harm or distress. Following the fall, the resident reported pain to the face and emotional distress, and was later transferred to a general acute care hospital for further evaluation. Medical records from the hospital indicated the resident was diagnosed with generalized anxiety disorder and had difficulty ambulating due to musculoskeletal weakness. The incident was reported to facility staff, and interviews confirmed the sequence of events leading to the resident's fall and subsequent injury.
Failure to Provide Necessary Behavioral Health Care and Individualized Care Planning
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizophrenia, depression, and anxiety disorder, who also had a history of aggressive behavior. The Minimum Data Set (MDS) assessment for this resident did not accurately reflect the resident's history of aggressive physical and verbal behavior, despite multiple documented incidents of aggression and disruption. The care plan for the resident was not individualized or effective, lacking specific interventions, supervision details, and frequency of re-evaluation. There was also a period when no behavior or schizophrenia care plan was in place for the resident. Multiple documented incidents showed the resident displaying aggressive and disruptive behaviors, including provoking other residents, yelling, and physically assaulting staff. On one occasion, the care plan addressing behavior problems was canceled, and for nearly two weeks, there was no care plan in place to address the resident's behavioral health needs. The MDS assessment contradicted the clinical record by indicating the resident did not exhibit physical or verbal behaviors toward others, despite clear evidence to the contrary in the clinical documentation. The lack of an accurate assessment and an effective, individualized care plan led to an incident where the resident entered another resident's room, resulting in a physical altercation. The resident struck another resident in the chest and required administration of multiple medications for aggressive behavior. Staff interviews confirmed that documentation of the resident's behavior was insufficient and that the interventions in place were not appropriate or effective for the resident's needs. Facility policies required comprehensive, person-centered care planning and prompt action to prevent resident-to-resident altercations, but these were not followed in this case.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
A deficiency occurred when a facility failed to ensure a safe and appropriate discharge for a resident with a complex medical and psychiatric history, including epilepsy, encephalopathy, anxiety disorder, and schizophrenia. The resident had fluctuating capacity to make medical decisions, was at risk for falls, and required assistance with ambulation, medication management, and activities of daily living. Despite these needs, the resident was discharged to an unlicensed board and care (B&C) facility that could not provide the necessary level of care, including ambulation assistance, epilepsy management, or medication administration and storage. The facility did not follow its own discharge and transfer policy and procedures, as the interdisciplinary team (IDT) did not conduct a discharge planning meeting prior to the resident's transfer. Key departments, including nursing, activities, and rehabilitation, were not notified or involved in the discharge planning process. The resident's care plan, which required coordination with rehabilitative therapies and community resources, was not implemented, and the discharge planning review form was incomplete. The facility also failed to verify the B&C's license, assess the appropriateness of the discharge location, or provide a hand-off report to the receiving facility regarding the resident's medical conditions and care needs. As a result of these failures, the resident experienced a series of adverse events after discharge, including a fall with head injury at the B&C, subsequent hospitalization, transfer between multiple facilities, and an episode of elopement that led to police intervention and further hospitalization. Interviews with facility staff and external providers confirmed that the resident's needs exceeded the capabilities of the B&C, and that critical steps in the discharge process, such as medication reconciliation, communication with the receiving facility, and post-discharge follow-up, were not performed.
Removal Plan
- The Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer policy and procedures. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility's Director of Nursing (DON)/Director of Staff Development (DSD)/Designee including the new processes implementation related to identified concerns to all active license nurses and IDT members.
- The facility has 30 licensed nurses and 24 have been provided with in-service and education. Facility does not have a licensed staff on vacation, leave nor FMLA (Family and Medical Leave Act).
- The Social Services consultant worked 1:1 with the Social Services Director (SSD). The SSD completed the Discharge Planning Review form, sections 1 (Discharge Goals/ General Information) A (Discharge Goals/ General Information) & B (Caregiver Responsibilities), 2 (Self Care Evaluation and Equipment) Q (equipment and supplies), Contacts and Sign and Date of the Discharge Summary, for training purposes.
- The facility DON and Medical Records initiated an audit to residents who have been discharged to a lower level of care in the past 30 days to ensure proper discharge planning was conducted prior to discharge with resident/responsible party, an IDT meeting was conducted prior to discharge, an endorsement of the resident's medical history and medication reconciliation was provided to receiving facility. No similar issues were identified.
- For those residents who lack capacity or with fluctuating capacity, the Office of Public Representative (OPR) will be contacted by the facility's SSD/Designee to act as an advocate in the discharge plan IDT prior to the discharge to ensure location is safe and appropriate given the residents' conditions. If the OPR does not wish to participate, the facility IDT in conjunction with the physician will hold an IDT meeting to review and document appropriateness.
- For those residents who lack capacity or with fluctuating capacity and have resident representatives, an IDT meeting will be held with the responsible party to review and discuss the discharge location for safety and appropriateness.
- Discharge planning will begin on the residents' admission to the facility.
- The Attending Physician and the IDT will review the residents' progress and determine a possible discharge date and document in resident's health record.
- The facility Admin notified Resident 1's attending physician, by phone of the concerns related to the resident's transfer to the Board and Care, the fall sustained and readmission to the hospital.
- The facility Admin notified facility Medical Director by phone of the Immediate Jeopardy that was issued, deficient practice and plan to correct.
- The facility Admin initiated a QAPI (Quality Assurance and Performance Improvement) regarding the Transfer and Discharge of residents.
- The facility staff will assist the physician and the resident to obtain medications after discharge from the facility. When discharged, remaining medications that have been administered to the resident while in the facility may be provided to the resident at the time of discharge if the medications were specifically ordered to be sent home with the resident.
- The Licensed Nurse will assure that the medication orders are reviewed with the resident and/ responsible party and explanation of all discharge medication orders occur at the time of discharge and documented on the resident's health record.
- The facility will ensure that the resident receives adequate follow-up including the ability to have a physician's prescription available to procure drug supply immediately after discharged from the facility and conduct a proper endorsement of resident's ordered medications and discharge instructions to the receiving facility and documented on the resident's health record.
- The facility's SSD and Admin located Resident 1. Resident 1 resided in Skilled Nursing Facility (SNF) 2 and was doing well.
- The facility's SSD/Designee will conduct a post discharge follow up call within 72 hours to ensure that the resident has transitioned adequately to the new facility/location moving forward.
- Newly hired licensed nurses/IDT will be educated by the facility's DON/DSD on facility's P&P pertaining to Discharge and Transfer of residents during their orientation and as needed.
Failure to Conduct Required IDT Meetings and Accurate Fall Risk Assessments After Multiple Falls
Penalty
Summary
The facility failed to implement its Fall Management Program policy and procedure by not conducting and initiating an Interdisciplinary Team (IDT) meeting after each of three falls sustained by a resident. The policy required the IDT to review and update the resident's fall risk status and care plan upon identification of a significant change of condition post-fall. Despite this requirement, the IDT meetings were not held after each fall, as acknowledged by the Director of Nursing (DON), and the care plan was not appropriately updated to address the resident's ongoing fall risk. The resident involved had a history of muscle weakness, abnormal gait, mobility issues, and alcoholic cirrhosis. Upon admission, the resident was identified as high risk for falls, with a fall risk score of 19.0, and required moderate assistance with activities of daily living. The resident experienced three falls within a short period, each documented in the medical record. After each fall, care plans were updated with interventions such as neuro checks, floor mats, and physical therapy consults, but the required IDT meetings to review the circumstances and revise the care plan were not conducted. Additionally, there were inaccuracies in the documentation of the resident's fall risk scores following each incident, with the scores decreasing despite repeated falls. The DON confirmed that these inaccuracies were due to incorrect information entered into the computer system. The failure to conduct IDT meetings and maintain accurate fall risk assessments resulted in the resident continuing to experience falls, with the potential for life-threatening injuries.
Failure to Document and Transcribe Treatment Orders for Resident's Skin Lesions
Penalty
Summary
The facility failed to implement treatment orders for skin lesions for one resident by not ensuring that physician orders were transcribed into the resident's treatment administration record. The resident, who was admitted with diagnoses including Parkinson's Disease, paranoid schizophrenia, and systemic involvement of connective tissue, had severely impaired cognition. The Wound Assessment and Plan indicated specific treatment orders for lesions on the resident's forehead and right ocular region, but these orders were not found in the Order Summary Report or documented in the Treatment Administration Record (TAR) for the relevant months. Interviews with the Treatment Nurse and the Director of Staff Development revealed that the orders for the resident's skin lesions were not entered into the electronic medical record (EMR), and there was no documentation of the treatments being performed. The facility's policy and procedure required that treatments administered be documented in the resident's medical record, and that medication and treatment orders be transcribed onto the appropriate administration record. The lack of documentation and transcription of orders placed the resident at risk of not receiving appropriate skin treatment and caused a delay in communication between licensed staff.
Failure to Prevent Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement its Abuse-Prevention, Screening, and Training Program policy, resulting in an incident where Resident 2 hit Resident 1 in the face. Resident 1, who was diagnosed with schizophrenia and anxiety disorder, was independent in daily activities and had intact cognitive skills. The incident occurred while Resident 1 was using the phone, and Resident 2, who had a history of schizophrenia and major depressive disorder with moderately impaired cognitive skills, approached and hit Resident 1. Resident 2's care plan required a 1:1 sitter to intervene as necessary to protect others, but the sitter was not close enough to prevent the incident. The Director of Nursing acknowledged that the staff failed to provide appropriate supervision, as the sitter was not maintaining a safe distance to effectively monitor Resident 2, who had a tendency to pace with aggressive behavior. The facility's policy clearly stated that no form of resident abuse or neglect was condoned, and physical abuse included actions such as hitting. The failure to adhere to the policy and provide adequate supervision led to the incident, compromising the safety and rights of the residents involved.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to monitor the behaviors of a resident who was prescribed psychotropic medications, which are used to treat psychiatric conditions by altering brain chemistry. The resident, who had diagnoses of schizophrenia and major depressive disorder, was prescribed Depakote, Invega Sustena, and Risperdal for mood disorder, aggressive behavior, and auditory hallucinations, respectively. However, there was no documented evidence of monitoring the resident's behaviors, such as labile mood, aggressive behavior, and auditory hallucinations, as required by the facility's policy. The Director of Nursing acknowledged the absence of documentation and emphasized the importance of monitoring to assess medication effectiveness and evaluate behavioral changes. The facility's policy on Behavior/Psychoactive Medication Management required monthly documentation of behavior occurrences and adverse reactions, but this was not adhered to in the case of the resident. The lack of behavior monitoring placed the resident at risk of not receiving necessary interventions for increased psychiatric behaviors and was considered inappropriate medication management. The deficiency was identified during a review of the resident's records and an interview with the Director of Nursing, who confirmed the failure to document and monitor the resident's target behaviors as per the facility's procedures.
Deficient Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain proper food storage and handling practices, as observed during a survey. In the walk-in refrigerator, three tomatoes were found with rotten spots, which the Dietary Supervisor (DSS) acknowledged should be discarded due to mold presence that could potentially make residents sick. Additionally, two pitchers of mixed lemonade and a package of powdered lemonade mix were improperly stored on the sink at the sanitizer/detergent mixing area, posing a risk of chemical contamination. The DSS confirmed that food should not be stored near chemicals to prevent mix-ups that could lead to resident illness. Furthermore, the coffee machine was found to have buildup in the sight glass tube, which the DSS indicated could harbor mold and pose a health risk to residents. The facility's policy and procedure on Food Storage and Handling, dated June 2024, mandates that cleaning supplies be stored separately from food and that fresh fruit be checked for ripeness and ordered frequently to ensure freshness. These observations highlight the facility's failure to adhere to its own policies, potentially leading to foodborne illnesses among residents.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering medications as ordered over a period from December 1, 2024, to January 9, 2025. The resident, who was admitted on December 17, 2024, had multiple diagnoses including parkinsonism, hepatic encephalopathy, diabetes mellitus, schizophrenia, epilepsy, anxiety, and depression. The resident's Minimum Data Set indicated severely impaired cognitive skills and dependency for activities of daily living, with routine antipsychotic medication use. The deficiency involved the failure to administer several medications as prescribed, including fluvoxamine maleate, pantoprazole sodium, demeclocycline HCL, risperidone, Vascepa, and lactulose. The Medication Administration Record (MAR) showed multiple instances where medications were not given, marked by the number '9' in the MAR box, indicating non-administration. Progress notes revealed that medications were often not available and were awaiting pharmacy delivery, leading to missed doses. During an interview and observation with the Director of Nursing (DON) and a Registered Nurse (RN), it was found that some medications were available in the medication cart but were not administered due to being stored in different drawers than expected. The DON acknowledged that the medications were available and should have been administered, emphasizing the importance of following physician orders to prevent complications. The facility's policy on medication administration requires that medications be administered as prescribed to ensure compliance with dose guidelines.
Deficiency in Medication Storage Cleanliness
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional principles, as evidenced by the presence of sticky residue in the bottom drawer of medication cart #3 and around the cap of a bottle of Pro-Stat liquid. During an observation, it was noted that boxes placed on the sticky residue in the drawer adhered to it, and the Pro-Stat liquid bottle was difficult to keep clean due to the residue. An interview with an LVN confirmed the presence of the sticky residue and acknowledged that the medication cart should be kept clean and free from such residue. The facility's policy and procedure on medication storage, dated August 2019, requires medication storage areas to be clean and free of clutter, and mandates the removal of contaminated or deteriorated medications.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to post the most recent survey results conducted by the California Department of Public Health (CDPH) in areas that are prominent and accessible to residents, their representatives, family members, and visitors. During an observation and interview, the Administrator admitted that the survey binder displayed in the hallway contained outdated results from May 2021, rather than the most recent survey conducted in December 2023. The Administrator acknowledged that the latest survey results were kept in her office and not made accessible to the residents and their families, which is a violation of the residents' rights. The facility's policy and procedure, as well as the admission packet, clearly state that residents have the right to examine the results of the most recent survey conducted by federal or state surveyors. These documents emphasize that the survey results and any plan of correction must be available for examination in a place readily accessible to residents. The failure to post the updated survey results hindered the rights of the residents and their families to be informed about the facility's compliance status and past performance history.
Failure to Maintain Sanitary Environment for Resident
Penalty
Summary
The facility failed to maintain a sanitary environment for one resident, identified as Resident 20, by not emptying the trash in a timely manner, which led to the production of gnats. Resident 20, who was admitted with diagnoses including hypertension, schizophrenia, and depression, was observed to have moderate cognitive impairment but was independent in dressing, bathing, and eating. During an observation and interview with the Infection Preventionist Nurse, the trash can in Resident 20's room was found overflowing with gnats present, indicating a risk of infection. The facility's policy requires providing a safe, clean, comfortable, and home-like environment, which was not adhered to in this instance.
Late Transmission of Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit the discharge Minimum Data Set (MDS) for a resident within the required 14 days after completion to the Center of Medicare and Medicaid Services (CMS). This deficiency was identified for one of the 22 sampled residents. The resident in question, who had diagnoses including schizophrenia, chronic obstructive pulmonary disease (COPD), and encephalopathy, was discharged to a General Acute Care Hospital on the same day the MDS assessment was dated. However, the MDS assessment was not transmitted until more than 14 days after the Assessment Reference Date (ARD), which was 4/22/2024. During an interview, the Minimum Data Set Nurse (MDSN) confirmed that the MDS assessment was completed and transmitted late, on 5/9/2024, instead of by the deadline of 5/6/2024. The Director of Nursing (DON) acknowledged that the delay in transmitting the MDS discharge assessment could affect facility reimbursement and staffing needs. The facility's policy and procedure on the RAI Process, dated 10/4/2016, requires timely submission of resident assessments to meet state and federal guidelines, which was not adhered to in this instance.
Failure to Complete PASARR Level II Evaluation for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level II evaluation was completed for one of the sampled residents, identified as Resident 40. This resident was admitted with diagnoses including diabetes mellitus, schizophrenia, and end-stage renal disease. The resident's admission record and subsequent assessments indicated a lack of capacity for medical decision-making, yet the Minimum Data Set (MDS) noted intact cognition. Despite these complexities, the required Level II evaluation was not conducted because the resident was reportedly unavailable for the assessment, possibly due to being out of the facility. The Minimum Data Set Nurse (MDSN) acknowledged that the staff should have resubmitted the Level I evaluation to schedule a Level II assessment. The absence of this evaluation meant that the facility did not have the necessary mental health recommendations to ensure appropriate placement and care for the resident. The facility's policy, dated July 2018, assigns the responsibility of updating PASARR evaluations to the MDS Coordinator, highlighting a lapse in following established procedures.
Failure to Develop Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan with measurable objectives, timeframes, and interventions for a resident who experienced significant weight loss. The resident, who had diagnoses including dementia, dysphagia, and severe protein-calorie malnutrition, lost 5.2% of their body weight in one week and 6.9% in one month. Despite these significant changes, the facility did not create a care plan to address the resident's nutritional needs, which was acknowledged by the Dietary Service Supervisor during a review of the resident's clinical records. The Minimum Data Set assessment indicated that the resident was not cognitively intact and required supervision for eating, oral hygiene, and upper body dressing. The facility's policy on Comprehensive Person-Centered Care Planning emphasizes the importance of updating care plans based on assessed needs, yet this was not done for the resident in question. The lack of a care plan for the resident's significant weight loss was identified as a deficiency, with the potential to place the resident at risk for further weight loss due to the absence of nutritional interventions.
Failure to Consistently Monitor Resident's Weight
Penalty
Summary
The facility failed to consistently monitor the weight of one resident, identified as Resident 56, which is crucial for managing their health conditions. Resident 56 had a history of Type 2 Diabetes Mellitus, unspecified protein-calorie malnutrition, a pressure ulcer, and anemia. The resident's weight was recorded as 180 pounds on June 14, 2024, and 171 pounds on both July 15 and July 22, 2024. However, there was no subsequent weight recorded after July 22, 2024, despite the resident being on an appetite stimulant, which necessitates regular weight monitoring to assess any significant weight changes. The facility's policy, titled 'Evaluation of Weight Nutritional Status,' mandates that weekly weights should be discontinued only when a resident's weight has been stable for four weeks, with monthly evaluations continuing for all residents. During an interview, RN 1 confirmed that weights should be taken monthly unless otherwise ordered. The failure to adhere to this policy for Resident 56, who was at risk for nutritional problems, meant that the facility staff could not effectively monitor and report significant weight changes to the doctor, potentially delaying necessary interventions.
Failure to Provide Vision Care Services
Penalty
Summary
The facility failed to provide necessary vision care services to a resident, identified as Resident 37, who reported missing prescription eyeglasses. Despite the resident's report to the facility staff about the missing eyeglasses two weeks prior, no follow-up action was taken to arrange for an optometry consult. The resident, who has diagnoses including parkinsonism, schizophrenia, and dysphagia, expressed difficulty in seeing print and television screens without the eyeglasses. The resident's last eye care consult was on 9/4/2023, and there was no subsequent follow-up, despite an order for eye health and vision consult being present in the resident's Order Summary Report dated 1/9/2025. Interviews with the Social Service Director (SSD) and the Director of Staff Development (DSD) revealed that the SSD acknowledged the lack of a written report regarding the missing eyeglasses and admitted it was her responsibility to refer the resident to an eye doctor. The facility's policy and procedure for referrals to outside services, which mandates coordination of such referrals by the Director of Social Services, was not followed. The DSD highlighted the risk of not referring the resident to an eye doctor, which could lead to worsening vision and affect the resident's quality of life. The facility's policy on resident rights emphasizes care that promotes quality of life and well-being, which was not upheld in this instance.
Failure to Implement Safety Measures for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 52, had a low bed and bilateral floor mats as per the physician's order, which was intended to enhance safety and prevent falls. Resident 52 was admitted with diagnoses including hypertension, dementia, and cardiomegaly, and was dependent on staff for various activities of daily living. The resident's care plan and fall risk evaluation indicated a risk for falls due to confusion, balance problems, and decreased muscle coordination. Despite these documented needs, an observation revealed that the resident's bed was not in a low position, and there were no floor mats present. During an interview and record review, a Licensed Vocational Nurse confirmed that the resident did not have the required safety measures in place, acknowledging that the resident was not safe and could be injured if a fall occurred. The facility's policies on fall management and resident safety, which emphasize providing a safe environment to minimize fall-related complications, were not adhered to in this instance. This oversight placed Resident 52 at risk for injury, highlighting a deficiency in the facility's adherence to prescribed safety protocols.
Failure to Document Midline Catheter Measurements
Penalty
Summary
The facility failed to properly measure and document the arm circumference and external catheter length for a resident with a midline catheter. This oversight was identified for one out of two residents who had a midline catheter, specifically Resident 56. The resident was admitted with conditions including Type 2 Diabetes Mellitus, a pressure ulcer, and a urinary tract infection. Despite the facility's policy requiring documentation of arm circumference and exposed catheter length, there was no record of these measurements in the resident's progress notes or IV administration record from November 22, 2024, to December 20, 2024. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the lack of documentation. The RN acknowledged the importance of assessing and monitoring the midline site for signs of infection, which includes measuring the arm circumference. The DON stated that these measurements should be taken at least weekly and documented to track the progress of the insertion site. However, the absence of such documentation indicated a failure to adhere to the facility's established procedures, potentially missing complications associated with the midline catheter for Resident 56.
Failure to Monitor Oxygen Saturation Levels
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 41, received proper monitoring for oxygen saturation levels as per the physician's order. Resident 41 was admitted with diagnoses including emphysema, schizophrenia, and hypertensive heart disease without heart failure. The physician had ordered oxygen at 2 liters to maintain oxygen saturation at or above 92% after the resident's saturation dropped to 88% on a previous occasion. However, the facility did not consistently monitor the resident's oxygen saturation levels, with gaps in monitoring noted between specific dates. During an observation, Resident 41 was found in bed without wearing oxygen, and a review of the resident's records revealed that oxygen saturation had not been checked for several days. An LVN confirmed that the staff had not been monitoring the resident's oxygen saturation as required, which could have resulted in the resident needing oxygen without receiving it. The facility's policy on obtaining vital signs indicated that vital signs should be taken before initiating treatment when there are conditional parameters, which was not adhered to in this case.
Failure to Post Updated Nurse Staffing Information
Penalty
Summary
The facility failed to post updated daily nurse staffing information, which is a requirement to ensure transparency and compliance with state regulations. During an observation and interview with the Director of Staff Development (DSD), it was revealed that the last posted nurse staffing information was dated 12/18/2024, indicating that the information was not current as of 1/7/2025. The DSD, who was new to the position, acknowledged the oversight and stated that the nurse staffing information should include both projected and actual hours worked by licensed nurses and CNAs, as well as the total number of residents in the facility. This information is crucial for determining if the facility meets the staffing hours required by the California Department of Public Health. The facility's policy and procedure, titled 'Nursing Department - Staffing, Scheduling and Posting,' dated 7/2018, mandates that nurse staffing data be posted daily at the beginning of each shift. The DSD emphasized the importance of posting and updating this information to ensure that the facility meets the needs of its residents and complies with state regulations. The failure to post updated staffing information was identified as a violation of resident rights, as it potentially deprived residents and the public of timely access to this critical information.
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What surveyors actually found near you
We read the 7,626 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Healthcare Center | 1.8 mi | ★★★★★ | 4 | 0 |
| University Park Healthcare Center | 1.8 mi | ★★★★★ | 31 | 0 |
| St. John Of God Retirement | 2.3 mi | ★★★★★ | 34 | 0 |
| East Terrace Rehabilitation & Wellness Centre, Lp | 2.4 mi | ★★★★★ | 27 | 0 |
| Sunnyview Care Center | 2.6 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 August 2026) and official state health department websites.