Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at View Heights Conv Hosp during CMS and state inspections, most recent first.
A resident with schizoaffective disorder and obesity fell in the hallway and sustained a closed head injury, dental fractures, and a finger fracture. Although there was an order to monitor orthostatic BPs in the lying, sitting, and standing positions, an LVN obtained the readings in the wrong sequence, using sitting, standing, then lying. RN and LVN interviews confirmed orthostatic BP monitoring was important for detecting orthostatic hypotension, and the facility’s lesson plan specified the correct order.
Inaccurate Orthostatic BP Documentation: A resident with HTN, DM, and schizoaffective disorder had orthostatic BP monitoring ordered, but the MAR showed the lying, sitting, and standing readings were all charted as the same value. An LVN stated she performed the assessment but entered the same numbers for all positions without verifying the actual measurements, resulting in inaccurate documentation of the resident’s orthostatic VS.
Dietary supervision requirements were not met when the facility employed two dietary supervisors who did not hold the required CDM or equivalent qualifications. One DS stated she did not have CDM certification, and the other held only a Food Protection Manager certification and acknowledged it did not meet regulatory requirements. Schedule review and staff interview showed there was routinely no dietary supervisor on duty on Wednesdays, and the ADM stated he was unaware the part-time DS did not meet the required credentials.
The facility failed to keep the dish machine at manufacturer-specified temperatures, with the wash cycle observed below required levels on multiple occasions and no maintenance requests available. The facility also failed to maintain proper kitchen hygiene when one food employee with facial hair did not wear a beard restraint while handling food and another employee wore excessive jewelry, including multiple bracelets, a watch, a necklace, and earrings, during soup preparation and food service.
Informed consent for psychotropic meds was not properly obtained or renewed for three residents. One resident with schizoaffective disorder and a PG had a Clozapine dose increase without a new consent, while two other residents with schizophrenia-related diagnoses had orders for Clozapine, Lithium carbonate, Haloperidol, and Seroquel without current consent renewals. The DON stated the facility’s records did not show the required signed, dated, and renewed consents for these psychotropic medications.
Failure to involve responsible parties in care planning: Two residents had changes to their care plans, including a low-fat diet and weight-related interventions, without proper participation from the RP or public guardian. One RP said he was never told about the resident’s weight, nutrition status, or planned weight loss, and the RD said she did not notify him when she changed the plan. For the other resident, the public guardian said she was unaware of care conference meetings, diet changes, and abnormal lab results, while the DON stated the guardian was supposed to be notified and involved in care decisions.
Two residents with intact cognition were not allowed to fully direct their diet and snack preferences. One resident with schizophrenia reported ongoing hunger, requested extra snacks, and said staff denied additional food while the RD pursued a low-fat, weight-loss-focused plan without notifying the RP. Another resident with schizophrenia and obesity was placed on a low-fat diet after abnormal labs, but the guardian was not properly included in care conference meetings or informed of the diet change and related lab results.
Failure to Notify Physician of Abnormal Lab Results: The facility failed to document physician notification of abnormal lab results for two residents. One resident had repeated abnormal valproic acid levels along with abnormal triglyceride, BUN, and creatinine results, and another resident had low and elevated valproic acid levels while receiving Depakote for behavior management. The DON stated there was no documentation that the physician was notified, and the facility policy required the attending physician to be notified of diagnostic test results.
Inadequate Monitoring of Psychotropic Medications: The facility failed to adequately monitor psychotropic medication use for several residents with schizophrenia, schizoaffective disorder, and cognitive impairment. Orders for lithium, Ativan, clozapine, and Remeron lacked specific target behaviors or were not paired with documented behavior monitoring, and staff interviews confirmed that effectiveness, continued need, and adverse effects were not consistently assessed or documented. One resident receiving Remeron was repeatedly observed sleepy and unarousable, while another resident’s Ativan use had no documented monitoring of the anxiety behavior it was intended to treat.
Delayed MDS for Significant Weight Loss: A resident with schizoaffective disorder and bipolar disorder had severe cognitive impairment and a marked weight loss of 19.6 lbs. in about one month. The RN stated the loss was significant and should have triggered further assessment of nutritional status, intake, and the effectiveness of current interventions, but there was no documented evidence that a significant change MDS was completed within the required timeframe. The DON confirmed that significant weight loss should prompt a significant change assessment and MDS review.
MDS Not Accurately Coded After Unwitnessed Fall: A resident with schizoaffective disorder and moderate cognitive impairment had an unwitnessed shower fall documented on a COC assessment, but the Quarterly MDS incorrectly showed no falls since admission. The RN who completed the MDS stated the fall should have been coded but was not, and that accurate coding would have supported care planning related to fall monitoring and prevention.
Missing Care Plan for Psychotropic Medication Use: A resident with schizoaffective disorder and severe cognitive impairment was receiving Trazodone at bedtime for lack of sleep, but the facility did not develop a care plan for psychotropic medication use. The DON stated the resident should have had a care plan to monitor for side effects and include non-pharmacological interventions to reduce or discontinue the medication, and the facility policy required documentation of resident or representative involvement in non-drug and medication interventions.
Failure to Revise Care Plan After Significant Weight Loss: A resident with schizoaffective disorder and bipolar disorder experienced significant wt loss, dropping from 225.6 lbs. to 189.2 lbs. in about 3 months. The RD stated the care plan should have been revised with updated, individualized nutritional interventions, but RN and DON confirmed the care plan was not updated after the wt loss was identified, despite the facility policy requiring revision when a resident’s condition changes.
Inaccurate Orthostatic BP Documentation for Multiple Residents: Staff failed to follow MD orders for orthostatic BP checks for three residents with psychiatric diagnoses and fall-related concerns. Records showed identical BP values documented for lying, sitting, and standing positions, and interviews revealed staff were taking BP in a seated position in the Utility Room or hallway and recording the same reading for all positions instead of performing true orthostatic measurements.
Failure to Address Significant Weight Loss: A resident with schizoaffective disorder and bipolar disorder experienced significant wt loss, dropping 19.8 lbs in about 1 month. The RD stated the loss was significant and should have triggered assessment of the cause and review of whether current nutritional interventions were effective. However, the care plan did not include additional nutritional interventions after the wt loss was identified, and RN and DON interviews confirmed the resident's intake, wt trends, food preferences, and need for additional nutritional approaches were not evaluated in the record.
A resident received metoprolol tartrate 25 mg BID for tachycardia, but the physician order did not include heart rate parameters or other clear instructions for when to give or hold the medication. During record review, the DON confirmed the order was incomplete and stated it should have been clarified before administration; the charge nurse job description also required discrepancies in physician orders to be reported to the nurse supervisor.
A resident with HTN and severely impaired cognition was ordered Lisinopril 20 mg at bedtime with instructions to hold if SBP was below 110 mm Hg. MAR review showed the medication was still administered on several occasions when SBP was 108 mm Hg and 106 mm Hg, and the RN and DON confirmed it should have been held when below the ordered parameter.
Medication Storage and Labeling Errors: An LVN found discontinued trazodone still in a med cart, an expired unlabeled bottle of Rybelsius, and three unidentified meds transferred into a urine specimen cup in the same cart. An unopened Ozempic pen for a cognitively intact resident was also stored on the cart instead of being refrigerated until first use, contrary to manufacturer guidance and facility policy.
A resident with hypocalcemia and idiopathic hypoparathyroidism had a nutritional assessment showing recent weight loss and an RD recommendation for double portions of protein at all meals, but the diet order was not updated for several weeks. During meal observations, the resident was served fish and milk despite documented dislikes, and the tray tag still reflected large portions instead of the current double-protein order. The RD stated the tray should have been adjusted to match the resident’s preferences and diet order.
Medical record documentation was not kept current for two residents with impaired decision-making. One resident with schizophrenia still had a former PG listed even though that person stated they were no longer responsible for care decisions, and another resident with schizoaffective disorder had a PG change noted in a progress note but the chart did not include contact information for the current PG. Staff confirmed the records were inaccurate and incomplete.
An LVN failed to perform hand hygiene after touching a paper bag of medications for a new admission and before preparing medications for another resident. The LVN acknowledged the lapse and stated the bag could not be considered clean. The DON stated nurses should perform hand hygiene after touching an object that has not been disinfected, and the facility policy required hand hygiene before preparing or handling medications.
Missing Privacy Curtains in Resident Room: A resident with schizophrenia, hyperglyceridemia, and nicotine dependence had no room curtains observed in place during an observation. HK stated curtains removed for cleaning should be replaced immediately with extra curtains to maintain privacy, and the ED stated the facility did not have extra curtains available when the curtains were being washed. The facility policy stated curtains are to be washed as needed and replaced immediately if spare curtains are available.
The facility failed to notify the physicians and conservators of two residents after another resident, with schizoaffective disorder and moderately impaired cognition, alleged she was raped by her roommates. The allegation was documented on a mandated reporting form, but there was no documentation in the progress or change-of-condition notes that the involved residents’ physicians or conservators were informed. An LVN confirmed that facility practice required a change-of-condition note to trigger such notifications, and an RN acknowledged she did not notify the physicians or conservators because she did not believe the allegation was substantiated. One conservator reported receiving no communication about the allegation. Facility policies required physician and conservator notification for unusual occurrences and changes in medical, mental, or psychosocial condition within the shift in which the change occurred.
A resident with schizoaffective disorder and moderately impaired cognition, but independent in ADLs, reported being raped by her two roommates, both of whom had psychotic disorders with intact cognition and were independent in ADLs. The allegation was documented on an SOC 341 form, yet the facility did not revise or implement care plan interventions or additional monitoring for the two accused residents. Review of their 2026 care plans and interview with the DON confirmed that no new safety interventions were added despite the report, contrary to the facility’s care plan guidelines requiring revisions when a resident’s condition or situation changes.
A resident with schizoaffective disorder and alcohol dependence, under a public guardian, was allowed to leave the facility on an Out on Pass without the required OOP Request Form and signatures from the interdisciplinary team in the clinical record. Staff interviews and record review confirmed the absence of this documentation, which is mandated by facility policy to ensure proper assessment and authorization before a resident leaves the facility.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes that affected the resident.
A resident with intact cognition and multiple diagnoses reported a lump at the back of the neck, which was brought to staff attention by a family member and the County Case Manager. Despite these notifications, an RN failed to assess the correct area, did not document the assessment, and did not notify the physician or respond to follow-up inquiries, resulting in a lack of timely evaluation and documentation as required by facility policy.
Staff did not monitor or document the aggressive behaviors of a resident with schizoaffective disorder and cognitive impairment, despite physician orders and facility policy. This failure was identified after the resident struck another resident and expressed intent to repeat the behavior. Staff interviews confirmed the resident's history of aggression and the lack of required monitoring.
The facility failed to provide a diet meeting residents' nutritional needs by serving a breakfast lacking adequate nutritional value and not having a system to ensure meal substitutes were of equal nutritive value. A mc muffin sandwich without meat was served, and the Dietary Supervisor was unaware of the requirement for sausage. Additionally, the facility lacked a nutritional analysis for meals, making it difficult to ensure alternatives were nutritionally adequate, potentially risking residents' nutritional status.
The facility employed a dietary supervisor (DS) who did not meet the required qualifications, such as having an associate's degree or certification in food service management. The DS, previously a cook, was overseeing kitchen activities and residents' dietary needs while still in school. The Registered Dietician was only present once a week, leaving the unqualified DS in charge on other days. The Director of Nursing was unaware of the educational requirements for the DS position.
The facility failed to provide breakfast sandwiches with sausage as per the menu for all residents. The Dietary Supervisor did not check the food before serving, and the Dietary Cook reported a lack of sausage in the kitchen. This oversight was a recurring issue, impacting the nutritional needs of residents.
The facility failed to ensure safe food storage practices, affecting all 146 residents. Observations revealed a walk-in refrigerator with unlabeled cheese, expired spinach, and undated lettuce, along with a dry storage room lacking a thermometer. Dietary staff confirmed these issues, and the facility's policies on food labeling and temperature monitoring were not followed, risking foodborne illnesses.
The facility's Arbitration Agreement failed to include a section for selecting a convenient venue for both parties, as discovered during an interview and record review. The Administrator admitted that the outdated agreement was provided to residents and their conservators, potentially causing bias in venue selection for binding arbitration agreements.
The facility failed to monitor washer water temperature and clean the dryer lint trap as per policy, leading to potential infection risks. The washer's temperature monitors were broken, preventing staff from ensuring proper disinfection of linen. Additionally, the dryer lint trap was not cleaned as required, which could affect the sanitizing process. The Infection Preventionist Nurse expressed concerns about the potential for improperly cleaned linen to cause infections among residents.
The facility failed to provide adequate seating in the dining room for all residents during mealtimes, resulting in some residents having to wait in line or return to their rooms until a seat became available. The dining room had only 40 chairs for 50 residents, leading to residents standing or being sent away, as confirmed by a CNA and the DON.
The facility failed to provide a dignified dining experience by not having enough seating for all residents, serving meals on disposable plates, and not ensuring simultaneous meal service at tables. Staff acknowledged these issues, which led to residents waiting for seats and meals, affecting their dignity.
The facility failed to obtain informed consent for psychotropic medications for three residents, resulting in the removal of their conservators' rights to make informed decisions. Informed consent forms were incomplete, lacking frequency and duration details for medications like Trazodone, haloperidol, Depakote, Buspirone, Ativan, and Zyprexa. This non-compliance with facility policy deprived conservators and guardians of necessary information for decision-making.
A facility failed to accurately document a resident's use of hypoglycemic medication in the MDS assessment. The resident, who had been receiving Insulin Glargine for type 2 diabetes, was not reported as being on this medication in the MDS. The MDS Coordinator confirmed the inaccuracy, which could affect the resident's care plan. Facility policy requires certification of assessment accuracy, which was not adhered to in this case.
A facility failed to create a care plan for a resident receiving Cymbalta for self-isolative behavior, despite no depression or anxiety diagnosis. The resident, with schizoaffective disorder, was independent and showed no aggressive behaviors. The DON admitted non-pharmacological interventions were not documented or attempted, contrary to facility policy, risking unnecessary medication use.
A resident with schizoaffective disorder was prescribed weekly Ozempic doses for diabetes management. An LVN documented the administration of the medication on a date prior to its actual administration, admitting to giving the dose a day late after the resident initially refused it. The facility's policy requires documentation only after administration, which was not followed.
The facility failed to monitor a resident's blood glucose before administering Insulin Glargine, risking hypoglycemia, and did not implement a physician's order for another resident's wound care, risking infection. The MAR did not prompt for glucose checks after a dosage change, and a wound care order was not transcribed, leading to these deficiencies.
A resident with schizophrenia, insomnia, and PTSD experienced a fall while walking to the dining room due to a loss of balance. Despite the facility's practice of conducting IDT conferences within seven days of an incident, no conference was held following the fall. The facility's policy requires investigations and interventions after a fall, but lacks a specific timeline for IDT conferences, potentially increasing the risk of recurrent falls.
Two residents in a LTC facility experienced medication administration errors. A resident received Ozempic from an expired pen, potentially affecting its effectiveness, while another resident was given Metformin too early, risking gastric distress. The facility's policies require medications to be administered as ordered, but these protocols were not followed.
The facility failed to monitor and document the use of psychotropic medications for two residents. One resident continued to receive Cymbalta without monitoring for depression or attempting a gradual dose reduction, despite the absence of symptoms. Another resident was prescribed haloperidol for schizophrenia without specifying the behaviors being treated, contrary to facility policy. The lack of documentation and clarification of medication orders led to potential unnecessary medication use.
A facility failed to manage a resident's Ozempic medication properly, as an injection pen was kept beyond its use-by date, and a Licensed Vocational Nurse did not label the pen with the correct open date. The resident, diagnosed with obesity, was prescribed Ozempic for weight management. The Director of Nursing confirmed that the pen should have been discarded after 56 days, and the incorrect labeling was acknowledged.
A facility failed to respect and document the food preferences and allergies of three residents, leading to potential health risks. One resident was not provided with a requested alternative meal, another's preference for fresh fruit as a snack was not documented or provided, and a third resident's dietary preferences and shrimp allergy were not properly documented, posing a risk of an allergic reaction. The facility's policies on food allergies and tray card systems were not adhered to.
The facility failed to provide snacks to two residents as requested, violating its Nourishment Policy. One resident, with schizoaffective disorder, was denied snacks outside scheduled times due to a lack of RD assessment. Another resident, also with schizoaffective disorder, was not given snacks despite expressing their importance. The DON confirmed that snacks should be provided when requested to prevent hunger and weight loss.
A facility failed to ensure a resident's conservator understood the Arbitration Agreement in their primary language, Spanish. The conservator, responsible for a resident with schizoaffective disorder and other dependencies, was given the agreement in English, which they did not fully comprehend. Although a translator explained the agreement, the conservator could not refer back to the document in Spanish, leading to a lack of understanding of the binding nature of the agreement.
The facility failed to report 24 COVID-19 positive residents to the CDPH as required, delaying the investigation and potentially increasing the spread of infections. Additionally, the facility did not implement its COVID-19 Mitigation Management Plan, as staff were observed not wearing masks properly. Interviews revealed a lack of awareness of reporting requirements, contributing to the deficiency.
A facility failed to report an abuse allegation involving a resident and staff to CDPH within the required two-hour timeframe. The resident, with schizoaffective disorder, reported being physically abused by staff after an incident of agitation. The DON cited fax transmission issues as the reason for the delay, which resulted in a delayed investigation by CDPH.
Incorrect Orthostatic Blood Pressure Technique After Resident Fall
Penalty
Summary
The facility failed to ensure orthostatic blood pressures were obtained for one resident according to the facility’s established procedure after a recent fall with injury. Resident 1 was admitted with diagnoses including schizoaffective disorder and obesity, and the MDS indicated moderately impaired cognitive skills for daily decision making while showing the resident was independent with ADLs. The resident also had a physician order to monitor and record orthostatic blood pressures in the lying, sitting, and standing positions every evening shift every four weeks on Tuesdays for orthostatic hypotension monitoring. After Resident 1 suffered a slip and fall in the hallway at the facility and was treated in the ED for a closed head injury, dental fractures, and a fracture to the right pinky finger, the facility’s medication administration audit showed the resident’s blood pressures were obtained in the order of sitting, standing, and then lying. RN 1 stated orthostatic blood pressures were important to detect orthostatic hypotension, and LVN 1 confirmed he used the sitting-first sequence when obtaining the measurements. The facility’s lesson plan instructed licensed nurses to obtain orthostatic blood pressures in the lying, sitting, and standing positions, and LVN 1 stated the incorrect technique could result in undetected orthostatic hypotension and delayed clinical intervention. The facility’s Falls Management System and Monitoring of Vital Signs policies stated the facility was to provide appropriate assessment and monitoring related to falls and changes in condition.
Inaccurate Orthostatic Blood Pressure Documentation
Penalty
Summary
The facility failed to ensure orthostatic blood pressure measurements were accurately documented for one sampled resident. Resident 2 was admitted with diagnoses including schizoaffective disorder, hypoosmolality, hypertension, and diabetes. The resident’s MDS indicated cognitive skills for daily decision making were intact and that the resident was entirely independent with ADLs. Physician orders dated 8/9/2024 directed staff to monitor and record orthostatic blood pressures in the lying, sitting, and standing positions every evening shift every four weeks on Tuesdays for orthostatic hypotension monitoring. During record review, Resident 2’s Monitoring MAR and Medication Administration Audit Report showed the orthostatic blood pressures in the lying, sitting, and standing positions were all documented as 139/85 mm Hg. The audit report showed the orthostatic vital signs were recorded at 6:47 p.m. In interview, the LVN stated she performed the orthostatic blood pressure assessment but inadvertently entered the same blood pressure values for all three positions without verifying the recorded measurements, and acknowledged the documentation was inaccurate. The facility’s Charting and Documentation policy stated all services provided to the resident would be documented in the medical record, and the Monitoring of Vital Signs policy stated the facility was to ensure optimum resident assessment and monitoring of resident change of condition.
Dietary Supervisor Lacked Required Qualifications
Penalty
Summary
The facility failed to employ a dietary supervisor who met the required qualifications of having an associate's degree or higher in food service management or hospitality, or being a certified dietary manager, certified food service manager, or holding national certification for food service management and safety. During interview and record review, Dietary Supervisor 1 was unable to produce credentials showing she was a Certified Dietary Manager and stated she did not have that certification, although she was in the process of scheduling an examination for June 2026. Dietary Supervisor 2 presented a Food Protection Manager certification dated 8/31/2025 and stated that this certification did not meet the regulatory requirements to function as a CDM or equivalent, and that he was enrolled in coursework to become eligible for CDM testing. Review of the dietary work schedules showed Dietary Supervisor 1 was not scheduled on Wednesday, Thursday, or Saturday, and a dietary aide stated that neither Dietary Supervisor 1 nor Dietary Supervisor 2 reported to work on 5/6/2026 because both were scheduled off on Wednesdays. The dietary aide stated it was routine to have no supervisor on duty on Wednesdays during the seven months employed at the facility. The Administrator stated he was not aware Dietary Supervisor 2's credentials did not meet regulatory requirements and acknowledged that hiring a CDM was required per regulations. The facility's job description for Dietary Supervisor stated the person selected must meet Federal and State laws or equivalent requirements.
Food Safety Deficiencies in Dishwashing and Staff Hygiene
Penalty
Summary
The facility failed to properly wash dishware using water temperatures below manufacturer specifications. During observation, the dishwashing machine was in use for soiled plate ware from breakfast service, and the sink reservoir thermometer read 96 degrees Fahrenheit while the inlet pipe thermometer read 117.6 degrees Fahrenheit. The dietary aide stated the dishwashing machine temperature was logged using the inlet thermometer and that a supervisor would be informed if temperatures were not to specifications. Facility records indicated wash temperatures must be 120 degrees Fahrenheit and that manufacturer guidelines should be followed for wash and rinse temperatures. On another observation, the dishwashing machine was again operating below the required temperature, with readings of 105 degrees Fahrenheit and later 90 degrees Fahrenheit during a concurrent observation with the dietary supervisor. The dietary supervisor verified the temperatures with an external probe thermometer and was unable to produce any maintenance requests. The supervisor stated she was unaware of any issues and acknowledged that lower operating temperatures than manufacturer specifications may result in bacteria not being killed properly and were unsanitary. The manufacturer’s installation instructions stated that supply water must have a minimum of 120 degrees Fahrenheit, with 130 to 140 degrees Fahrenheit recommended for best results. The facility also failed to maintain hygienic practices in the kitchen. One food employee with a goatee was observed preparing soup and later transferring and serving food without a beard restraint properly worn; the restraint was hanging around his neck during food handling. In a separate observation, another food employee was preparing soup while wearing excessive jewelry, including a necklace, five bracelets, a watch, and four earrings. Facility policies required beard restraints when facial hair is visible and limited jewelry to non-excessive items, and the administrator stated the jewelry worn was excessive.
Informed consent for psychotropic medications was not obtained or renewed
Penalty
Summary
The facility failed to implement its Informed Consent policy for three sampled residents receiving psychotropic medications. For Resident 18, who was admitted with schizoaffective disorder and had severe cognitive impairment with a public guardian, the record showed Clozapine was ordered at 200 mg in the morning and 300 mg at bedtime. The DON stated that when Resident 18’s Clozapine dose was increased, the facility did not obtain a new informed consent form, even though the guardian should have been notified of the change and given the opportunity to consent to or refuse the new dose. For Resident 97, who was admitted with schizoaffective disorder, insomnia, and stimulant dependence and whose MDS indicated intact cognitive skills for daily decision making, the record showed orders for Clozapine 300 mg at bedtime, Haloperidol 20 mg three times daily, Clozapine 50 mg in the morning, Clozapine 50 mg at noon, Lithium carbonate 900 mg in the morning, and Seroquel 25 mg at bedtime. During review with the DON, the physician orders did not show evidence of informed consent or renewal for Clozapine, Haloperidol, Lithium carbonate, or Seroquel. The DON stated these medications required informed consent before initiation and that consent should be signed, dated, maintained in the record, and renewed when doses increased or when existing consent expired. For Resident 24, who had schizophrenia and was readmitted to the facility, the MDS indicated intact cognitive skills for daily decision making and independent ADLs, and the resident received antipsychotic medication. The record showed orders for Lithium carbonate 150 mg twice daily and Clozapine 200 mg twice daily. During review with the DON, the informed consent forms for Lithium and Clozapine were present but were not renewed. The facility policy stated that written informed consent for psychotropic drugs was required, with renewal every six months, but the consents in the record did not reflect current renewal.
Failure to Involve Responsible Parties in Care Planning
Penalty
Summary
The facility failed to ensure that two sampled residents’ responsible parties were given the opportunity to participate in care planning and changes to the residents’ plans of care. For one resident with diagnoses including paranoid schizophrenia, the record showed the resident had intact cognitive skills for daily decision making and was ordered a low-fat diet and Metformin. The resident’s responsible party stated the facility never discussed the resident’s weight, nutritional status, or planned weight loss, and said he would not have agreed to a weight loss program without being consulted first. The Registered Dietician stated that when she adjusted the resident’s care plan to include a low-fat diet and encouragement of weight loss, she did not notify the responsible party and did not routinely consult responsible parties when altering plans of care. The DON stated the responsible party was expected to be notified of planned diet changes and had the right to accept or decline changes to the care plan. The DON also stated the RD was to educate, but not make decisions on behalf of residents or their responsible parties. For the second resident, who had diagnoses including schizophrenia and obesity and did not have cognitive impairment, the record showed case conference meetings were held and the resident later had abnormal triglycerides and was placed on a low-fat diet. The public guardian stated she did not recall receiving notification of care conference meetings, had not participated in care planning since admission, and was unaware of the diet change and abnormal lab results. The DON stated the public guardian was to be notified of all case conference meetings and was entitled to be involved in care decisions, while RN 3 stated the facility could not locate records showing the public guardian was notified of the case conferences.
Failure to Honor Resident Diet and Snack Preferences
Penalty
Summary
The facility failed to ensure two sampled residents were permitted to make choices about their diets and snack preferences. Resident 89 had diagnoses including paranoid schizophrenia, was documented as cognitively intact for daily decision making, and was able to eat independently. Her records showed she was on a low-fat diet with regular-sized meal portions, and the RD documented goals of gradual weight loss and encouraged small portions and increased physical activity. Resident 89 told surveyors she wanted extra snacks such as a baloney sandwich or banana between meals, said she still felt hungry after lunch, and stated she was limited to one snack item at 8:00 p.m. She also reported that when she asked for more food, staff denied the request and told her to speak with the RD, who told her she was obese. During an interview, Resident 89 appeared fearful and nervous when trying to ask for a snack. Resident 89’s responsible party stated the facility never discussed her weight, nutritional status, or a planned weight loss program, and said he would not have agreed to Resident 89 being on a weight loss program. The RD stated she changed Resident 89’s care plan, including the low-fat diet and encouragement of weight loss, without notifying the responsible party and said she based the decision on her own judgment. The DON stated the RD was expected to notify responsible parties when there were plans to change a resident’s diet and that the responsible party had the right to accept or decline changes to the care plan. Resident 54 also had diagnoses including schizophrenia and obesity and was documented as cognitively intact. The record showed a low-fat diet order after abnormal triglyceride results, and care conference records indicated a case conference was held without the guardian present on one occasion and with email notification but no attendance on another occasion. The guardian stated she did not recall receiving notification of care conference meetings, had not participated in care planning since admission, and was unaware of the diet change and abnormal lab results. The DON stated the guardian was to be notified of all case conference meetings because she was actively providing input in care decisions, and RN 3 stated the facility could not locate records showing the guardian was notified of the meetings.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of abnormal laboratory results for two residents. Resident 89 had multiple abnormal lab values, including low valproic acid levels on 8/6/2025, 10/23/2025, and 1/23/2026, as well as abnormal triglyceride, BUN, and creatinine results on 10/23/2025 and 4/23/2026. Resident 89’s record showed diagnoses of paranoid schizophrenia, hypokalemia, hypo-osmolality, hyponatremia, and anemia, and the 2/6/2026 MDS indicated intact cognitive skills for daily decision making and independence with most ADLs except personal and oral hygiene. During interview, the DON stated there was no documentation that these abnormal lab values were reported to the physician, and stated it was best practice to notify the doctor of all abnormal laboratory results. Resident 57 also had abnormal valproic acid levels that were not documented as reported to the physician, including a low level on 5/8/2025 and elevated levels on 9/2/2025 and 10/24/2025. Resident 57’s diagnoses included schizoaffective disorder, and the MDS indicated moderate cognitive impairment with independence for all ADLs except personal and oral hygiene. The care plan for anticonvulsant medication Depakote directed staff to monitor labs as ordered by the physician. The DON stated there was no documentation that the physician was notified of the abnormal valproic acid results and stated the licensed nurse was expected to notify the physician as soon as results were reviewed, or at least within 24 hours. The facility policy titled Laboratory, Radiological, and Diagnostic Results stated the attending physician was to be notified of diagnostic test results.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring of psychotropic medications for four sampled residents who were receiving medications for behavioral or psychiatric indications. The deficiency involved Resident 5, Resident 18, Resident 57, and Resident 109, where the record review, observations, and staff interviews showed that the facility did not consistently document specific target behaviors, monitor those behaviors for effectiveness, or reassess continued need for the medications as ordered. For Resident 5, the record showed diagnoses of schizophrenia and insomnia, and the care plan addressed lithium related to schizoaffective disorder and manic speech with rapid thought process. The physician order dated 1/8/2026 directed lithium carbonate 150 mg in the morning for manic speech and rapid thought process, but the medical record did not contain a physician order for behavior monitoring of those symptoms. During interview, the LVN stated there should always be orders to monitor the indicated behavior of psychotropic medications and that the lack of monitoring placed the resident at risk of unidentified and unaddressed changes in behavior. The DON stated monitoring indicated behaviors was important to identify trends or changes and to support physician reassessment or medication adjustment. For Resident 18, the record showed schizoaffective disorder and severe cognitive impairment. The resident had orders for Ativan 0.5 mg twice daily for anxiety manifested by tearful and irritable behavior, lithium carbonate 300 mg twice daily for manic symptoms, and clozapine 200 mg in the morning and 300 mg at bedtime for psychosis. The DON stated the behavioral indications for these medications were different and required behavior monitoring for their specific indications, but the orders for lithium and clozapine were not specific enough for staff to monitor effectiveness. The DON also stated the monitoring records did not document the frequency of tearful and irritable behavior related to Ativan, and staff were unable to monitor the effectiveness of lithium carbonate and clozapine because the target behaviors were not clearly identified. For Resident 57, the record showed schizoaffective disorder and moderate cognitive impairment. The resident had Ativan orders for anxiety, but the orders did not identify the specific anxious behavior. The monitoring records from July 2025 and from January through May 2026 did not show behavior monitoring for anxiety, a specific anxious behavior, or the resident’s use of Ativan. The DON stated the order was not specific enough for staff to adequately monitor effectiveness, that there was no documentation showing why Ativan was started, and that there was no documentation that the medication’s effectiveness was being monitored. For Resident 109, the record showed schizophrenia and severely impaired cognitive skills for daily decision making. The resident was ordered Remeron 15 mg at bedtime for appetite, but observations on multiple days showed the resident lying in bed with eyes closed and unarousable, and staff stated the resident was usually sleepy and often skipped breakfast. The LVN stated there was no documented assessment of continued need or effectiveness for appetite stimulation, and the DON stated there was no documented evidence that the facility assessed continued need, evaluated effectiveness, monitored for adverse effects, or notified the physician regarding the repeated sleepiness and inability to be aroused.
Delayed MDS for Significant Weight Loss
Penalty
Summary
The facility failed to ensure a MDS for a significant change was completed within 14 days for one sampled resident after the resident experienced significant weight loss. Resident 30 was admitted with diagnoses including schizoaffective disorder and bipolar disorder, and the 2/8/2026 MDS indicated severely impaired cognition and independence with ADLs. A review of the weight and vitals summary showed the resident weighed 225.6 lbs. on 1/27/2026 and 206 lbs. on 2/23/2026, reflecting a loss of 19.6 lbs. and 8.8% of body weight in about one month. During interview and record review, the RN responsible for MDS completion stated the weight loss was significant and should have triggered further assessment of the cause, nutritional status, intake, and whether current nutritional interventions were effective. The RN stated there was no documented evidence that a significant change MDS was completed within 14 days after the weight loss was identified. The DON stated residents with significant weight loss should be assessed for significant change in condition and that a significant change MDS should be completed within 14 days when the resident's condition declined and required review and revision of care and services. The facility policy stated the assessment coordinator must ensure the interdisciplinary team conducts and reviews resident assessments within 14 days of a significant change in condition.
MDS Not Accurately Coded After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for Resident 57 after an unwitnessed fall. Resident 57 was admitted with schizoaffective disorder and was documented on the MDS as having moderate cognitive impairment and being independent with all ADLs except personal and oral hygiene. A Change of Condition assessment documented that Resident 57 slipped and fell to the floor while in the shower on 8/29/2025, and the fall was unwitnessed. However, the Quarterly MDS later indicated Resident 57 had no falls since admission. During interview, the RN who completed the MDS stated the unwitnessed fall should have been coded on the MDS but was not. The RN stated that accurately indicating the fall would have prompted staff to develop a care plan to monitor for fall complications, identify the cause of the fall, and try to prevent additional falls. The facility policy on Falls Management System stated residents are to receive appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs, and the MDS policy stated the assessment is used to identify impairments and support care planning.
Missing Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a care plan for psychotropic medication use for one resident who was receiving Trazodone 50 mg at bedtime for lack of sleep. The resident was admitted with schizoaffective disorder and had severe cognitive impairment on the MDS dated 2/16/2026. The physician order dated 2/29/2024 directed Trazodone at bedtime, and during interview the DON stated the resident received Trazodone for lack of sleep and that there should have been a care plan to monitor for side effects and include non-pharmacological interventions to reduce or discontinue the medication. The record review also showed the facility's Care Planning policy stated care plans were to identify resident needs and develop a comprehensive plan to meet psychiatric, psychosocial, and medical needs. The Psychotropic Medication Use and Monitoring policy stated the resident or representative should be involved in discussion of potential non-drug and medication interventions to manage behaviors, and that this involvement should be documented in the medical record. The report did not identify a care plan for the resident's psychotropic medication use or documentation of non-pharmacological interventions related to the Trazodone order.
Failure to Revise Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to revise the comprehensive care plan and nutritional interventions for Resident 30 after the resident experienced significant weight loss. Resident 30 was admitted with diagnoses including schizoaffective disorder and bipolar disorder, and the MDS dated 2/8/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired while the resident was independent with ADLs. A review of the weight and vitals summary showed Resident 30 weighed 225.6 lbs. on 1/27/2026 and 189.2 lbs. on 5/2/2026, a loss of 36.6 lbs. in approximately three months. The RD stated the weight loss was significant and that the care plan should have been revised with updated, individualized nutritional interventions. RN 3 reviewed the care plan titled Weight and stated it addressed risk for weight loss but was not revised with additional interventions after the significant weight loss was identified. The DON stated residents with significant weight loss should have their comprehensive care plans reviewed and revised to include updated interventions based on current condition and needs, and the facility policy stated care plans were to be reviewed and revised whenever a resident’s condition changes.
Inaccurate Orthostatic Blood Pressure Monitoring and Documentation
Penalty
Summary
The facility failed to follow physician orders for orthostatic blood pressure monitoring and recording for three residents. For Resident 57, who had schizoaffective disorder, moderate cognitive impairment, and a history of falls, the physician ordered orthostatic blood pressure checks in lying, sitting, and standing positions every four weeks. The record showed repeated documentation of identical blood pressure values for all three positions. During interview, RN 2 stated the CNAs obtained blood pressures in the Utility Room or hallway, that she only checked blood pressures in emergencies, and that she used a seated blood pressure reading to document the lying and standing values because there was no surface in the Utility Room for a resident to lie on. For Resident 124, who had schizoaffective disorder, insomnia, and suicidal ideations, the physician ordered orthostatic blood pressure monitoring in lying, sitting, and standing positions every four weeks. The monitoring record showed identical blood pressure readings documented for all three positions on multiple occasions. During interview, LVN 2 stated she had never taken an orthostatic blood pressure that resulted in the same value for lying, sitting, and standing, and stated it appeared the orthostatic blood pressure was not actually taken and that one blood pressure value was used for all three positions. The DSD stated orthostatic blood pressure taking was not a skill LVNs or CNAs were taught or evaluated on upon hire, and the facility had not conducted in-services on the task. For Resident 2, who had schizoaffective disorder and major depressive disorder, the physician ordered orthostatic blood pressure monitoring in standing, lying, and sitting positions every four weeks. The monitoring record showed the same blood pressure value documented in all three positions. During interview, the DON stated blood pressure readings would typically vary between positions and that identical readings were not an appropriate or expected orthostatic result. The DON stated the documentation suggested staff likely obtained only one blood pressure reading and recorded it for all three positions instead of performing the ordered orthostatic assessment correctly. The facility's Falls Management System policy stated residents were to receive appropriate assessment and interventions to prevent falls and minimize complications if a fall occurred, and the Charge Nurse job description included taking and recording blood pressures.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure appropriate nutritional interventions were implemented and evaluated for one resident after significant weight loss was identified. The resident was admitted with diagnoses including schizoaffective disorder and bipolar disorder, and the MDS dated 2/8/2026 indicated severely impaired cognitive skills for daily decision making while showing the resident was independent with ADLs. A review of the weight and vitals summary showed the resident weighed 225.6 lbs on 1/27/2026 and 206 lbs on 2/23/2026, reflecting a loss of 19.8 lbs, or 8.8% of body weight, in about one month. The RD stated this weight loss was significant and that the resident should have been assessed to determine the cause and whether current nutritional interventions were effective. The record review and staff interviews showed the care plan titled Weight, dated 1/26/2026, did not include additional nutritional interventions after the significant weight loss was identified. RN 3 stated the care plan addressed risk for weight loss but was not revised with additional interventions after the resident's continued weight loss was identified. The DON stated residents with significant weight loss should be assessed and monitored, and that the interdisciplinary team should have evaluated intake, weight trends, food preferences, and the need for additional nutritional approaches. The facility policy titled Weight Assessment and Intervention stated that weight changes of 5% or more should be retaken the next day for confirmation, the dietitian should be notified in writing if verified, and undesirable weight changes should be elevated by the treatment team.
Incomplete Metoprolol Order Lacked Heart Rate Parameters
Penalty
Summary
The facility failed to ensure the physician order for metoprolol tartrate included heart rate parameters before administration for one sampled resident. Resident 121 was admitted with diagnoses including schizoaffective disorder, alcohol dependence, opioid dependence, anemia, and thrombocytopenia. The resident's MDS dated 3/27/2026 indicated cognitive skills for daily decision making were intact and that the resident was independent with ADLs. During a concurrent interview and record review on 5/6/2026, the DON reviewed the physician order dated 1/27/2026 for metoprolol 25 mg twice daily for tachycardia. The DON stated the order did not include specific parameters or clinical instructions for when the medication should be administered or held based on the resident's heart rate range. The DON stated the incomplete order should have been clarified with the physician before administration, and that nursing staff were responsible for reviewing orders for completeness, accuracy, and safety before carrying them out. The facility's Charge Nurse Job Description stated that discrepancies noted concerning physician orders are to be reported to the nurse supervisor.
Lisinopril Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure that Lisinopril was administered within the ordered hold parameters for one resident with hypertension and severely impaired cognition. The resident’s care plan directed staff to administer Lisinopril as ordered, and the physician order dated 3/20/2026 specified Lisinopril 20 mg by mouth at bedtime with instructions to hold the medication if systolic blood pressure was less than 110 mm Hg. A review of the MAR showed that Lisinopril was administered on multiple occasions when the resident’s systolic blood pressure was below the ordered parameter, including readings of 108 mm Hg on 3/21/2026, 3/22/2026, and 3/23/2026, and 106 mm Hg on 4/3/2026 and 4/4/2026. During interviews, RN 1 stated the nurse was responsible for checking blood pressure and holding the medication when the systolic blood pressure was below 110 mm Hg, and the DON confirmed the medication should not have been given below that threshold and was not administered in accordance with the physician’s ordered parameters.
Medication Storage and Labeling Errors
Penalty
Summary
Discontinued trazodone HCl for a resident with schizophrenia, anemia, and alcohol abuse was found in the bottom drawer of North Station Medication Cart 2 during an observation with an LVN. The resident’s physician order had discontinued trazodone HCl 100 mg at bedtime for insomnia, but the bubble pack remained in the cart instead of being removed and disposed of in the destruction bin in the locked medication storage room. The LVN stated the medication should have been removed and that leaving discontinued medication in the cart placed residents at risk of medication errors. An expired bottle of Rybelsius was also observed in North Station Medication Cart 2 without a resident label and with an expiration date of 7/31/2025. The LVN stated she did not know which resident the bottle belonged to and said it should have been labeled with the resident’s name and removed when it expired. The DON stated expired medications should be removed from the cart and that medications should be labeled with residents’ names to ensure correct administration. Three different medications were found transferred into a urine specimen cup in the same medication cart, with a handwritten label of hydroxyzine 50 mg. The LVN stated she did not know which medications were in the cup, which residents they were ordered for, or their expiration dates, and said only pharmacists could place medications into a container. In addition, an unopened Ozempic prefilled pen for a cognitively intact resident with schizoaffective disorder, anemia, and insomnia was observed on the south station front medication cart instead of being refrigerated until first use, and the LVN stated it should have been stored in the refrigerator per manufacturer guidance.
Failure to Follow Resident Food Preferences and Protein Portion Order
Penalty
Summary
Resident 105, who had diagnoses of hypocalcemia and idiopathic hypoparathyroidism and was noted on the MDS to have disorganized thinking, had a nutritional assessment on 4/7/2026 that identified a gradual 0.6% weight loss over the prior 30 days. The RD documented that his caloric needs might not be met, recommended removing large portions at all meals, and recommended updating the diet order to include double portions of protein at all meals. The assessment also documented that Resident 105 requested double portions of protein. The physician order reflecting double portions of protein at all meals was not updated until 5/4/2026, despite the RD stating during interview that the change should have been completed within 24 to 48 hours. During a concurrent review, the RD confirmed that the recommendation for double portions of protein had been made on 4/7/2026 but was not entered into the diet order until 5/4/2026. The RD stated the timely update was important to honor the resident's preference and ensure he received the additional calories. During dining observations, Resident 105 was served food that did not match his documented preferences and diet order. On 5/5/2026, his tray tag showed that he disliked milk and fish, yet his lunch tray contained fried fish and two cartons of milk. The RD stated he should not have received those items and that staff should have removed the milk and offered a substitution, such as juice, and should have provided a sandwich with double portions of deli meat instead. On 5/6/2026, Resident 105's tray tag still reflected large portions rather than his current order for double portions of protein, and his lunch tray contained one whole green chili cheese square and a half-sized square. The RD stated kitchen staff used the tray tag when plating the tray, and the facility policies required food preferences to be followed and nutritional recommendations to be completed within three days.
Medical Record Did Not Reflect Current Public Guardian Information
Penalty
Summary
The facility failed to ensure that the Public Guardian information in the medical record was reviewed and updated for two sampled residents. Resident 109 was admitted with a diagnosis of schizophrenia, and the MDS dated 3/18/2026 indicated severely impaired cognitive skills for daily decision making. During a telephone interview, Resident 109’s former PG stated she was no longer the resident’s PG as of 1/2026 and was no longer responsible for decisions or notifications regarding the resident’s care. However, the medical record continued to list that former PG, and Social Services confirmed the information was not current. Resident 105 was admitted and later re-admitted with a diagnosis of schizoaffective disorder, and the MDS indicated disorganized thinking. The resident stated he did not make medical decisions for himself. A telephone call to the PG listed in the admission record reached the Public Guardian’s office, where staff stated there was no one by that name. A progress note documented that Social Services had been informed the resident’s PG was now PG 5, but the record did not include contact information for PG 5. Staff interviews confirmed the medical record still listed the old PG information and did not contain documentation showing how to contact the current PG.
Failure to Perform Hand Hygiene During Medication Preparation
Penalty
Summary
The facility failed to ensure LVN 4 performed hand hygiene between residents during medication preparation. During an observation in the South Back Nursing Station, LVN 4 was seen touching a paper bag filled with medications for a new admission and then preparing medications for another resident without performing hand hygiene. During an interview, LVN 4 stated he did not perform hand hygiene after touching the paper bag and before preparing the next resident’s medications, and stated he should have done so because he did not know where the bag had been and could not consider it clean. The DON stated licensed nurses should perform hand hygiene after touching an object that has not been disinfected during medication preparation. The facility policy on handwashing/hand hygiene stated that if hands are not visibly soiled, alcohol-based hand rub should be used before preparing or handling medications.
Missing Privacy Curtains in Resident Room
Penalty
Summary
Privacy curtains were not in place in Resident 15’s room. Resident 15 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, hyperglyceridemia, and nicotine dependence. The MDS dated 4/18/2026 indicated the resident was cognitively intact and independent for eating, toileting, and bathing. During an observation on 5/4/2026 at 10:10 a.m., no room curtains were observed hanging in Resident 15’s room. During a concurrent observation and interview on 5/4/2026 at 2:36 p.m., Housekeeping stated that when room curtains are removed for cleaning, the Janitor should replace them with extra curtains to ensure resident privacy, and that staff should have replaced the curtains immediately after taking them down. The Environmental Director later stated that extra curtains were not available on 5/4/2026 when Resident 15’s curtains were being washed, and that the facility should have had extra curtains available to replace them while they were being washed. The facility policy dated 12/2025 stated curtains are to be washed semi-annually or when soiled or requested, and replaced immediately if spare curtains are available or if damaged or torn.
Failure to Notify Physicians and Conservators After Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians and conservators of a change in condition following an allegation of sexual abuse involving three residents. Resident 1, who had schizoaffective disorder and moderately impaired cognition but was independent with ADLs, reported that she was raped by her roommates, Resident 2 and Resident 3, on or about 4/13/2026 or 4/14/2026. This allegation was documented on an SOC 341 form dated 4/14/2026. The SOC 341 form did not indicate that the physicians or conservators for Resident 2 and Resident 3 were notified of the allegation. Resident 2 had a diagnosis of schizophrenia, intact cognition, and was independent with ADLs. Resident 3 had schizoaffective disorder, intact cognition, and was also independent with ADLs. Review of Progress Notes and Change of Condition Notes for Residents 2 and 3 from 4/13/2026 through 4/15/2026 showed no documentation that their physicians or conservators were notified of Resident 1’s allegation of rape involving them. LVN 1 confirmed during interview that the facility’s standard process required initiation of a Change of Condition Note to ensure physician and conservator notification after such an allegation, and acknowledged that in the absence of this documentation, those notifications were not completed. RN 1, who was the assigned nurse for all three residents when the allegation was reported on 4/14/2026, stated she did not notify the physicians or conservators for Residents 2 and 3 because she did not believe the allegation was substantiated. Resident 3’s conservator reported not receiving any emails or calls from the facility regarding the allegation of sexual misconduct. The DON stated that for any allegation of sexual abuse, licensed nursing staff were expected to initiate a Change of Condition Note to ensure notification of the physician and conservators for all residents involved, including alleged perpetrators, and that this was necessary to address potential changes in the residents’ mental or physical condition. Facility policies on Reporting of Unusual Occurrences and Change in a Resident’s Condition required physician and conservator notification when unusual occurrences or changes in medical or mental condition occurred, including incidents and changes in psychosocial status, within the shift in which the change occurred.
Failure to Revise Care Plans After Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement care plan interventions with measurable actions and timetables for two residents after an allegation of sexual abuse. Resident 1, who had schizoaffective disorder and moderately impaired cognition but was independent with ADLs, reported that she had been raped by her two roommates (Residents 2 and 3) on or around mid-April 2026. This allegation was documented on an SOC 341 form, which noted Resident 1’s report of rape by her roommates but did not indicate that additional monitoring or safety measures were initiated for Residents 2 and 3. Resident 2 had schizophrenia with intact cognition and was independent in ADLs, and Resident 3 had schizoaffective disorder with intact cognition and was also independent in ADLs. Review of their care plans dated in 2026 showed no care plan revisions or new interventions following Resident 1’s allegation of rape against them. During an interview and concurrent record review, the DON confirmed that care plans for Residents 2 and 3 did not include interventions developed in response to the allegation and stated that care plans should have been developed and implemented to ensure immediate safety interventions. The facility’s own care plan guidelines policy, revised in December 2024, required that care plans be revised as changes in a resident’s condition dictate, but this was not done in response to the reported incident.
Failure to Maintain Complete Clinical Records for Resident Out on Pass
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible clinical records for a resident who went Out on Pass (OOP) with a family member. The resident, who had a diagnosis of schizoaffective disorder and alcohol dependence and was under the care of a public guardian, had an approved OOP request for a specific date and time, as indicated by the Conservatee Leave Request form. However, upon review, the resident's clinical records did not contain the required OOP Request Form or the document titled 'Signing Residents Out on Pass' for the date in question. Interviews with facility staff, including the Social Services Assistant, Registered Nurse, Medical Records Assistant, and Director of Nursing, confirmed that the OOP Request Form, which should be signed by the Program Director, Social Services Director, and DON as part of the interdisciplinary team assessment, was missing from the resident's chart. Facility policy requires that the OOP Request Form be completed and signed by the appropriate team members to ensure the resident's safety and compliance with program requirements before leaving the facility. The absence of this documentation meant that the necessary assessment and authorization process was not properly documented or followed for the resident's OOP. This deficiency was identified through interviews and record reviews, which consistently indicated that the required documentation was not present in the resident's clinical records for the specified OOP event.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Timely Assess and Document Resident's Neck Lump
Penalty
Summary
A deficiency occurred when a resident with a history of schizoaffective disorder, alcohol dependence, and nicotine dependence reported a lump at the back of his neck. The resident stated that a family member had likely informed the nurse about the lump. Despite an email from the County Case Manager to the facility's RN requesting an assessment of the lump, there was no documentation in the resident's progress notes indicating that an assessment was performed or that the physician was notified. The RN acknowledged receiving the request and stated that only the front of the resident's neck was checked, not the back where the lump was located. The RN did not document any findings or respond to the County Case Manager's follow-up email. The Director of Nursing confirmed that nurses are expected to assess residents when concerns are raised by family members and to document all findings and actions in the medical record. The facility's policies require comprehensive assessments and documentation of all services provided. In this case, the lack of timely assessment, failure to notify the physician, and absence of documentation regarding the resident's lump constituted the deficiency.
Failure to Monitor and Document Aggressive Behavior in Resident with Psychiatric Diagnosis
Penalty
Summary
Facility staff failed to monitor a resident with a known history of verbal and physical aggression, as ordered by the physician. The resident, diagnosed with schizoaffective disorder and exhibiting cognitive impairments, had a physician order in place requiring staff to monitor and document episodes of verbal and physical aggression. Despite this order, review of the behavior monitoring flowsheet revealed that staff did not document or monitor the resident's aggressive behaviors. The Director of Nursing confirmed that the monitoring was not completed as required, and the purpose of the monitoring was to identify escalating behaviors and prevent further incidents. This deficiency was highlighted when the resident struck another resident in the face without provocation and expressed a desire to hit someone again. Interviews with staff indicated that the resident had a history of aggressive behavior and was considered a safety risk to others. Facility policies required monitoring of residents at risk for unsafe behavior, but these procedures were not followed, resulting in a lack of documentation and monitoring for the resident's aggression.
Deficiency in Nutritional Value of Meals and Lack of Nutritional Analysis System
Penalty
Summary
The facility failed to provide a diet that met the nutritional needs of all residents by not ensuring that breakfast offered adequate nutritional value and by lacking a system to ensure meal substitutes and alternatives were of equal or nutritive value. During an observation, it was noted that a mc muffin sandwich without meat was served to residents, containing only scrambled eggs. The Dietary Supervisor (DS) and Dietary Cook (DC) acknowledged the absence of sausage, which was supposed to be part of the meal, and admitted that this issue had occurred previously. The DS was unaware that the sandwich required meat and failed to check the food served to residents, which was crucial to prevent weight loss. Additionally, the facility did not have a system to determine the nutritional values of the menus provided to residents. The Registered Dietician (RD) confirmed that the facility lacked a nutritional analysis for the meals served, making it difficult to ensure that meal alternatives like peanut butter sandwiches, grilled cheese sandwiches, or chef's salads were of similar nutritive value. The RD stated that without knowing the nutritional content of the planned menu and alternatives, there was a potential risk for residents to experience malnourishment and loss of muscle mass. The Director of Nursing (DON) emphasized that meals should meet residents' nutritional needs to prevent undesired weight loss.
Unqualified Dietary Supervisor Employed
Penalty
Summary
The facility failed to employ a dietary supervisor (DS) who met the necessary qualifications, which include having an associate's degree or higher in food service management or hospitality, being a certified dietary manager, certified food service manager, or having national certification for food service management and safety. The DS was recognized only for completing a basic food handler course and was still enrolled in relevant courses, indicating she was not yet qualified for the position. Despite this, she was overseeing kitchen activities and residents' dietary needs while still in school. Interviews revealed that the DS began working in December 2024 and was previously a cook at the facility. The Registered Dietician (RD) was only present at the facility on Tuesdays, leaving the DS in charge on other days despite her lack of qualifications. The Director of Nursing (DON) admitted to not knowing the educational requirements for the DS position and confirmed that the DS was not qualified. The facility's job description for the Director of Food Services required the DS to be a graduate of an accredited course in dietetic training and registered as a food service director in the state, which the current DS did not fulfill.
Failure to Follow Dietary Menus for Breakfast
Penalty
Summary
The facility failed to ensure that dietary staff followed the dietary menus for all 146 residents by not providing a breakfast sandwich with sausage as specified in the menu. During an observation, it was noted that the breakfast sandwiches served contained only scrambled eggs, lacking the sausage patty that was required according to the facility's recipe and menu. The Dietary Supervisor (DS) was unaware that the breakfast sandwich was supposed to include sausage and did not check the food before it was served to residents. This oversight was confirmed during an interview with the DS, who admitted to not noticing the absence of sausage in the breakfast sandwiches. Further investigation revealed that the Dietary Cook (DC) was aware that the breakfast sandwich should have included sausage but did not have any available in the kitchen. The DC had informed the DS about the lack of sausage, yet the sandwiches were still served without it. This issue had occurred previously, indicating a recurring problem with food supply or menu adherence. The facility's policy and procedure for menu planning, as well as the job descriptions for the cook and the Director of Food Services, emphasize the importance of following menus to meet residents' nutritional needs, which was not adhered to in this instance.
Deficient Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, affecting all 146 residents. During an initial kitchen tour, surveyors observed several deficiencies, including a walk-in refrigerator containing a bag of cheese without a use-by date, expired bags of spinach, and unlabeled lettuce. Additionally, the dry storage room lacked a thermometer to monitor room temperature, which is essential for ensuring food safety. Interviews with dietary staff confirmed these observations, with the dietary cook acknowledging the absence of proper labeling and the expired spinach, and the dietary supervisor emphasizing the importance of dating food items to prevent serving old food to residents. The facility's policies and procedures for dry storage and refrigerated storage were not followed, as evidenced by the lack of a thermometer in the dry storage room and the improper labeling and dating of food items in the refrigerator. The facility's policy indicated that storeroom temperatures should be maintained between 50 to 70 degrees Fahrenheit and that a thermometer must be present to monitor these temperatures. Furthermore, the policy required that all food items in the refrigerator be covered, labeled, and dated to ensure they are used within the correct timeframe. The failure to adhere to these policies had the potential to result in harmful bacteria growth and cross-contamination, posing a risk of foodborne illnesses to all residents receiving food from the kitchen.
Arbitration Agreement Lacks Venue Selection
Penalty
Summary
The facility failed to include a selection of a venue that was convenient to both parties in their Arbitration Agreement, which is meant to resolve disputes between the facility and residents through a neutral arbitrator rather than going to court. During an interview and record review, it was found that the facility's Resident-Facility Arbitration Agreement, which was undated, did not reflect the updated version that included this crucial section. The Administrator acknowledged that the facility's administration was responsible for providing the updated agreement to the Admissions Coordinator, who would then review it with the resident and their conservator. However, the residents and their conservators were given the outdated version of the agreement, potentially causing bias in the venue selection process for those entering into a binding arbitration agreement.
Failure to Monitor Laundry Water Temperature and Clean Dryer Lint Trap
Penalty
Summary
The facility failed to adhere to its Water Temperature Policy for Facility Laundry and Preventative Maintenance Policy, leading to potential infection risks. On 2/14/2025, it was observed that the washer water temperature monitors were broken, preventing staff from ensuring that the water temperature was maintained between 125-165 degrees Fahrenheit as required. The Maintenance Supervisor (MS) admitted that staff were unable to verify if the linen was being properly cleaned or disinfected due to the lack of temperature monitoring. Additionally, the MS mentioned that the facility relied on the chlorine in the washing solution for disinfection, but acknowledged uncertainty about the effectiveness without knowing the water temperature. Furthermore, the facility did not follow its policy regarding the cleaning of the dryer lint trap. On the same day, it was observed that the lint trap contained lint, and the MS confirmed that staff were supposed to clean the lint trap twice per shift, starting at 5:30 a.m. However, the dryer lint removal log showed no documentation of cleaning at 7 a.m. or 9 a.m. The MS stated that failing to clean the lint trap could lead to a fire risk and affect the dryer temperature, potentially compromising the sanitizing process of the linen. The Infection Preventionist Nurse (IPN) expressed concerns that the dryer might not kill all bacteria and viruses if the lint trap was not clean, and that the uncertainty about the washer water temperature could result in improperly cleaned linen, posing an infection risk to residents.
Inadequate Dining Room Seating
Penalty
Summary
The facility failed to accommodate all residents in the dining room during mealtimes, as observed on multiple occasions. The dining room was equipped with only 40 chairs, while the north side of the facility housed 50 residents. This lack of seating resulted in residents having to wait in line or be sent back to their rooms until a seat became available. On several occasions, residents were observed standing in the dining room or at the entrance, waiting for a seat, and were instructed by a Certified Nursing Assistant (CNA) to wait against the wall or return to their rooms. Interviews with the CNA and the Director of Nursing (DON) confirmed that the dining room could not accommodate all residents simultaneously, leading to the practice of having residents wait or return to their rooms. The DON acknowledged that this practice could negatively impact residents' feelings, as they were made to wait to eat. The facility's policy indicated that meals should be distributed promptly and that residents should be encouraged to sit in a dining room chair, highlighting a discrepancy between policy and practice.
Dining Experience Deficiencies Affect Resident Dignity
Penalty
Summary
The facility failed to provide a dignified dining experience for residents, as observed during multiple instances where the dining room did not have enough space or seating for all residents to eat at the same time. Residents were seen waiting in line or being sent back to their rooms due to insufficient seating. Staff, including a CNA and the DON, acknowledged the lack of space and chairs, which led to residents having to wait against the wall or return to their rooms until a seat became available. Additionally, the facility did not ensure that all residents sitting at the same table received their meals simultaneously. Observations showed that staff distributed food trays in a disorganized manner, skipping some residents and causing delays. The DON admitted there was no specific process for distributing food trays, which resulted in some residents having to wait longer for their meals. The facility also used disposable plates and bowls due to a shortage of regular plates, which was against the facility's policy. This practice was acknowledged by the DS and DC 2, who stated that it was not appropriate and did not provide a homelike environment. The use of disposable items was only meant for extenuating circumstances, yet it was observed during regular meal service, potentially affecting residents' dignity and self-worth.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to three residents, which resulted in the removal of their conservators' rights to make informed decisions about their care. Resident 31 was administered Trazodone without prior informed consent from their conservator. The facility's policy required informed consent to be obtained and verified before the initial administration of psychotropic medication, but this was not done for Resident 31. Additionally, the Verification of Informed Consent forms for Resident 31 were incomplete, lacking the frequency of administration for Trazodone, haloperidol, and Depakote. Resident 16's informed consent forms for Buspirone, Ativan, and Zyprexa were also incomplete, missing the frequency of administration. Despite having intact cognitive skills for daily decision-making, Resident 16 had a public guardian responsible for their care. The facility's failure to include the frequency of medication on the informed consent forms deprived the public guardian of the necessary information to make informed decisions about the resident's treatment. Similarly, Resident 347's informed consent form for Zyprexa was incomplete, lacking the frequency and duration of administration. Resident 347, who had intact cognitive skills for daily decision-making, also had a public guardian. The facility's policy required that the nature of the procedures, including their probable frequency and duration, be included in the informed consent. The absence of this information on the informed consent forms for all three residents indicates a failure to comply with the facility's policy and deprived the conservators and guardians of their right to make informed decisions about the residents' care.
Inaccurate MDS Assessment for Resident on Hypoglycemic Medication
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, identified as Resident 31, by not indicating that the resident was on hypoglycemic medication. This inaccuracy was discovered during a review of the resident's records, which showed that the MDS did not reflect the resident's ongoing treatment with Insulin Glargine, a medication used to manage type 2 diabetes mellitus. The resident's Admission Record and Order Recap Report confirmed the use of Insulin Glargine, which had been administered for an extended period. The Minimum Data Set Coordinator (MDSC) acknowledged the discrepancy during an interview and record review, confirming that the MDS inaccurately reported the resident's medication status. The facility's policy requires all personnel completing any part of the Resident Assessment to certify its accuracy, highlighting a lapse in adherence to this policy. This failure had the potential to negatively impact the resident's plan of care and the delivery of necessary services related to diabetes management.
Failure to Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a care plan for a resident who was administered Cymbalta for self-isolative behavior, despite the absence of a diagnosis of depression or anxiety. The resident, who was admitted with a diagnosis of schizoaffective disorder, did not exhibit cognitive impairments or aggressive behaviors and was independent in mobility and eating. The physician's order for Cymbalta was based on self-isolative behavior, yet no care plan was created to address this behavior or to explore non-pharmacological interventions prior to the use of psychotropic medication. The Director of Nursing acknowledged the absence of a care plan and stated that non-pharmacological interventions, such as counseling and group activities, should have been attempted and documented before resorting to medication. The facility's policies emphasized a holistic approach to behavior management, requiring thorough assessment and individualized interventions. The lack of a care plan placed the resident at risk of receiving unnecessary medication and potential side effects, as non-drug approaches were not documented or attempted as per the facility's guidelines.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration by a Licensed Vocational Nurse (LVN) for a resident. The resident, who was diagnosed with schizoaffective disorder and had no cognitive impairments, was prescribed a weekly dose of Ozempic for type 2 diabetes management. The Medication Administration Record (MAR) indicated that the resident received the scheduled doses on specific dates. However, an observation revealed that the Ozempic injection pen was empty, and a sealed pen was found unused, indicating a discrepancy in the administration record. Further investigation showed that the LVN documented the administration of the medication on a date prior to its actual administration. The LVN admitted to administering the dose a day later than scheduled after the resident initially refused and then agreed to take the medication. The Director of Nursing confirmed that medications should be documented as administered only after they are given, as per the facility's policy. This failure in documentation had the potential to delay the resident in reaching her care goals.
Failure to Monitor Blood Glucose and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure quality care for two residents by not clarifying and monitoring blood glucose levels for one resident and not implementing a physician's order for wound treatment for another. For Resident 31, the facility did not monitor blood glucose levels before administering Insulin Glargine on multiple occasions. The Licensed Vocational Nurse (LVN) acknowledged that the Medication Administration Record (MAR) did not prompt for blood glucose checks after the insulin dosage was changed, leading to potential risks of hypoglycemia. Resident 31 was admitted with diagnoses including schizophrenia, type 2 diabetes mellitus, and hyperlipidemia. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and independence in daily activities. Despite the change in insulin dosage, the MAR failed to include a prompt for blood glucose monitoring, which was a standard practice when the resident was on a higher insulin dose. The facility's policy required clarification of any discrepancies in medication orders, which was not adhered to in this case. For Resident 16, the facility did not follow the physician's order to cleanse a scalp wound daily, which was not transcribed to the MAR. The resident, who had a history of schizoaffective disorder and diabetes mellitus, was observed with dried blood and staples on the scalp, indicating the wound had not been cleansed since hospital discharge. The Infection Preventionist Nurse confirmed the risk of infection due to the lack of wound care. The facility's policy required that all physician orders be added to the MAR or treatment record, which was not done in this instance.
Failure to Conduct IDT Conference After Resident Fall
Penalty
Summary
The facility failed to conduct an Interdisciplinary Care Team (IDT) conference following a witnessed fall involving a resident on December 19, 2024. The resident, who was diagnosed with schizophrenia, insomnia, and PTSD, experienced a fall while walking to the dining room for breakfast due to a loss of balance. Despite having intact cognitive skills for daily decision-making and being independent in most activities, the resident required setup assistance with oral and personal hygiene and experienced hallucinations, delusions, and disorganized thinking. The resident also expressed the importance of having family or a close friend involved in care discussions. The Director of Nursing (DON) confirmed that no IDT conference was conducted for the fall incident, which is contrary to the facility's practice of holding such conferences within seven days of an incident to prevent recurrence. The facility's Fall Management System policy, approved in April 2023, mandates that investigations and appropriate interventions be initiated at the time of a fall and reviewed by Nursing Management in subsequent meetings. However, the policy does not specify a timeline for conducting an IDT conference after a fall. The lack of an IDT conference following the fall had the potential to increase the risk of recurrent falls for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents. For Resident 56, a Licensed Vocational Nurse (LVN) administered five doses of Ozempic, a medication used to treat type 2 diabetes mellitus, from an injection pen that was 35 days beyond its use-by date. This was observed during a review of the medication cart and storage room, where it was noted that the pen should have been discarded after 56 days of opening. The Director of Nursing (DON) confirmed that using the expired pen could lead to decreased effectiveness of the medication, potentially affecting the resident's weight loss treatment. For Resident 49, the facility failed to administer Metformin, a medication for diabetes, at the correct time. The medication was given more than one hour before the scheduled administration time, which was supposed to coincide with meals. The DON stated that the medication should be administered with or immediately after meals to avoid gastric distress. The early administration was observed, and it was noted that dinner was not served until later, indicating the medication was given on an empty stomach. The facility's policies and procedures, as well as the job description for LVNs, require medications to be administered as ordered by the physician and within a specific time frame. The observed deficiencies in medication administration for both residents highlight a failure to adhere to these protocols, potentially compromising the residents' health outcomes.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. For Resident 3, the staff did not monitor for self-isolating behaviors and did not attempt a gradual dose reduction (GDR) for Cymbalta, which was prescribed for depression. Despite the absence of depression symptoms, as indicated in the Psychotropic Monthly Summary assessments, the medication was continued without documented monitoring or a GDR attempt. The Director of Nursing (DON) acknowledged the lack of documentation and monitoring, stating that a GDR should have been completed if the behavior was not present. For Resident 31, the facility failed to document behavior manifestations for the use of haloperidol, an antipsychotic medication prescribed for schizophrenia. The medication order did not specify the behaviors being treated, which is necessary for appropriate monitoring and care. The Registered Nurse (RN) and DON both stated that the order should have been clarified to include specific behaviors, as the diagnosis alone was not a sufficient indication for the medication. The order for haloperidol had been active since 2018 without clarification. The facility's policy on psychotropic medication use requires that such medications be used to treat specific behaviors and symptoms, with clinical indications and at the lowest possible doses. However, the facility did not adhere to this policy for Residents 3 and 31, as there was a lack of monitoring, documentation, and clarification of medication orders, leading to the potential for unnecessary medication use.
Medication Management Deficiency: Improper Labeling and Disposal of Ozempic Pen
Penalty
Summary
The facility failed to properly manage the medication of a resident, specifically concerning the use and labeling of an Ozempic injection pen. The Ozempic pen, used to treat type 2 diabetes mellitus, was kept in the medication cart beyond its use-by date of 12/31/2024. Additionally, a Licensed Vocational Nurse (LVN) did not label the pen with the correct open date, which could lead to the administration of medication with reduced potency. During an observation, it was noted that the pen was opened on 11/5/2024 and was empty, yet it was still present in the cart without a replacement. The facility's Director of Nursing confirmed that the pen should have been discarded after 56 days, and the incorrect labeling of the open date was acknowledged. The resident involved, who was admitted with a diagnosis of obesity, was prescribed Ozempic to be administered every seven days. The Medication Administration Records indicated that the resident received five doses from the pen opened on 11/5/2024. The failure to dispose of the pen after the recommended period and the incorrect labeling of the new pen's open date were identified as deficiencies. The Director of Nursing emphasized that the medication should not be used past its use-by date to ensure its effectiveness, particularly for the resident's weight loss treatment.
Failure to Document and Respect Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to respect and document the food preferences and allergies of three residents, leading to potential health risks. Resident 97 was not provided with a requested alternative meal of cheese quesadillas, despite the kitchen having the necessary ingredients. The resident's preference was not documented in the diet order, and the available alternatives did not meet the resident's satisfaction, potentially risking malnutrition. The Registered Dietician (RD) confirmed that the substitution process was not followed correctly, and the resident's nutritional needs were not met. Resident 51 expressed a preference for fresh fruit as a snack, which was not documented or provided. The RD was unaware of this preference, and there was no system in place to ensure that residents' food preferences were assessed and documented. The lack of documentation meant that staff were unaware of the resident's preference, and the resident continued to receive less healthy snack options. Resident 81's dietary preferences and allergies were not properly documented or respected. The resident's preference to avoid beans was not noted on the diet card, and the resident's shrimp allergy was not listed, posing a risk of an allergic reaction. The RD and Dietary Supervisor acknowledged the importance of documenting allergies and preferences to prevent exposure to allergens and ensure residents' dietary needs are met. The facility's policies on food allergies and tray card systems were not adhered to, leading to these deficiencies.
Failure to Provide Snacks as Requested
Penalty
Summary
The facility failed to adhere to its Nourishment Policy by not providing snacks to two residents, Resident 56 and Resident 81, as requested. Resident 56, who was diagnosed with schizoaffective disorder, alcohol dependence, and nicotine dependence, reported that when he asked for snacks, the nurses did not provide them. The facility's policy allowed for snacks at specific times, and additional snacks required approval from the Registered Dietician (RD) after an assessment. However, Resident 56 was not on the list to receive snacks at 10 a.m. and 8 p.m., and the RD stated that additional snacks would not be provided until she assessed the resident, which did not occur promptly. Similarly, Resident 81, who also had schizoaffective disorder and was under the care of a public guardian, expressed that snacks were important to him, yet he was not provided with them when requested. The Director of Nursing (DON) acknowledged that residents should be given snacks when requested, and withholding them could lead to hunger and weight loss. The facility's policy indicated that snacks should be available to residents outside of scheduled times, but this was not followed, leading to the deficiency.
Failure to Provide Arbitration Agreement in Language Understood by Conservator
Penalty
Summary
The facility failed to ensure that the conservator of a resident understood the Arbitration Agreement in a language they comprehended. Resident 21, who was admitted with diagnoses including schizoaffective disorder, alcohol dependence, and nicotine dependence, had a conservator responsible for making decisions on their behalf. The conservator's primary language was Spanish, but the Arbitration Agreement was provided in English, which the conservator did not fully understand. During interviews, it was revealed that the facility only offered the Arbitration Agreement in English, and although a translator explained the agreement in Spanish, the conservator could not refer back to the document in their primary language. This resulted in the conservator not having a full understanding of the binding nature of the Arbitration Agreement, as they were unable to explain what arbitration was.
Failure to Report COVID-19 Outbreak and Implement Mitigation Plan
Penalty
Summary
The facility failed to report 24 COVID-19 positive residents to the California Department of Public Health (CDPH) as required by the All Facilities Letter 23-08. This letter mandates the reporting of outbreaks and unusual infectious disease occurrences to the local public health officer and CDPH. The failure to report these cases resulted in a delay in the investigation by CDPH, potentially increasing the spread of COVID-19 infections within the facility. Additionally, the facility did not implement its COVID-19 Facility Mitigation Management Plan, which required all Health Care Personnel (HCP) to be provided with and wear facemasks or N95 masks while working in the facility. Observations revealed that staff members, including an Activity Assistant and a Laundry Assistant, were not wearing their masks properly, which could contribute to the spread of infection among residents and staff. Interviews with the Infection Preventionist (IP) and a Public Health Nurse (PHN) highlighted a lack of awareness and understanding of the reporting requirements. The IP was unaware of the need to report the outbreak to the Licensing and Certification District Office, and the PHN confirmed that the outbreak was not reported until several days after the initial positive test results. The facility's policy and procedure document also outlined the requirement for daily reporting of COVID-19 data to CDPH, which was not adhered to in this instance.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a staff member and a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe, as outlined in their policy and procedure. The incident involved a resident with a history of schizoaffective disorder, nicotine dependence, and homelessness, who reported being hit, kicked, and kneed by staff after becoming agitated. The resident had the capacity to make themselves understood and was independent in activities of daily living. The delay in reporting the incident resulted in a delay in the investigation by CDPH, potentially placing the resident and others at risk for further abuse. The Director of Nursing (DON) acknowledged the failure to report the incident in a timely manner, citing issues with fax transmission attempts that were not completed. The facility's policy, as well as an All Facilities Letter, clearly stated the requirement to report such incidents within two hours. Despite attempts to send a fax report, the facility was unaware that the transmission had not gone through, leading to the deficiency in timely reporting. Interviews with the Registered Nurse and DON confirmed the expectation to report abuse immediately to ensure resident safety and compliance with regulations.
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What surveyors actually found near you
We read the 7,051 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Avalon Villa Care Center | 0.3 mi | ★★★★★ | 59 | 0 |
| Rosecrans Care Center | 1.6 mi | ★★★★★ | 26 | 0 |
| Gardena Convalescent Center | 1.9 mi | ★★★★★ | 16 | 0 |
| Kei-ai South Bay Healthcare Center | 2 mi | ★★★★★ | 16 | 0 |
| Memorial Hospital Of Gardena D/p Snf | 2.5 mi | ★★★★★ | 13 | 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.