Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Park Convalescent Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a history of anxiety experienced acute agitation and refused medication and hospital transfer. A nurse practitioner ordered a one-time dose of Ativan to manage the resident's behavioral distress and facilitate transport, but there was no documentation or recollection that informed consent was obtained prior to administration, contrary to facility policy requiring prescriber-obtained consent for psychotropic medications.
A resident with a history of falls, impaired cognition, and mobility issues experienced a fall resulting in a hip fracture after the facility failed to complete a thorough fall risk assessment and did not implement or document individualized fall prevention interventions such as tab alarms or regular rounding, despite facility policy and staff awareness of the resident's high fall risk.
A resident with complex medical and mobility needs missed multiple doctor's appointments and blood work because the facility arranged transportation that did not accommodate requirements for a bariatric van or gurney. Staff and documentation confirmed that the resident was dependent for transfers and that inappropriate vehicles were repeatedly sent, leading to appointment cancellations.
Kitchen staff did not label cilantro, lettuce, and carrots with delivery or use-by dates, and some vegetables were stored while brown and wilted. Additionally, a dietary staff member failed to wash hands after donning a hairnet and before handling food, contrary to facility policy.
Two residents with limited English proficiency and cognitive capacity were not treated with dignity and respect by a medication nurse, who failed to communicate in a language they could understand and responded dismissively when another resident attempted to assist. The DON acknowledged that miscommunication could cause frustration and that staff should facilitate interpretation, as required by facility policy.
Two residents with documented language preferences other than English were not provided communication in their preferred language, despite being cognitively intact and having these needs identified in their assessments. One resident reported difficulty communicating with medication nurses and was not offered interpretation or alternative communication methods. The DON confirmed that interventions such as obtaining staff to interpret should be used, but these were not implemented, resulting in unmet communication needs.
A resident with multiple chronic conditions and a language preference other than English did not receive ordered as-needed pain medication and was not educated about his pain medications in an understandable language. Despite active orders for both ibuprofen and Percocet, only ibuprofen was administered, and the resident was left confused about his pain management regimen.
Surveyors found that the facility did not maintain a clean and safe environment for all residents, as evidenced by a leaking pipe in one medication room and a cockroach infestation in another. The issues were not reported or addressed by staff or the Maintenance Supervisor, and pest control records showed no treatment for the affected area, despite facility policies requiring regular maintenance and pest control.
A cook did not follow the standardized recipe for Szechwan pork by adding salt, pepper, and garlic powder, which were not included in the approved recipe. This action was observed and confirmed by interviews with the cook, the RD, and the DON, all of whom stated that recipes must be followed to meet therapeutic dietary needs, especially for residents with hypertension.
A container of jelly with an open date beyond the allowed 30-day period was found in a refrigerator, and both the RD and DON confirmed it should have been discarded according to their understanding of safe food handling practices. Facility policy on storage duration conflicted with staff statements, but the outdated jelly remained in the refrigerator, indicating a lapse in proper food storage procedures.
Surveyors found a resident bathroom with three soiled towels, a used coffee cup, and a water pitcher and cup left above the sink, in violation of infection control protocols. Staff interviews confirmed these items should not have been present due to infection control concerns, and facility policy requires all staff to follow procedures to prevent the spread of communicable diseases.
Twenty resident rooms were found to be below the federally required minimum square footage for multiple occupancy, with each room housing three residents in less than 240 sq. ft. Despite residents reporting adequate space and observations showing sufficient room for movement and care, the facility did not meet the regulatory standard for room size.
A resident with diabetes, congestive heart failure, and hypertension was inaccurately documented as receiving insulin on the MDS assessment, even though the insulin order had been discontinued prior to the assessment period. This error was identified through record review and staff interviews, revealing that the MDS did not accurately reflect the resident's medication status.
A resident with multiple medical conditions and no natural teeth was not assisted in obtaining replacement dentures after her original set went missing. Despite documented care plans, a dental consult indicating interest in dentures, and staff awareness of the issue, the facility did not make a timely dental referral or provide adequate follow-up, resulting in ongoing difficulty with eating and poor meal intake.
A CNA failed to don the required PPE when entering an isolation room during an influenza outbreak, despite facility policies and training. The resident had severe cognitive impairment and was on droplet precautions due to RSV exposure. This lapse in protocol increased the risk of infection spread.
A facility failed to ensure a resident with a gastrostomy tube and NPO order had appropriate orders for blood sugar checks every six hours. The resident, with severe cognitive impairment and multiple diagnoses including diabetes, was dependent on staff for daily activities. Despite the care plan indicating the need for Accu-checks, there were no specific orders for NPO status or separate blood glucose checks. Interviews confirmed the absence of necessary orders, potentially leading to inaccurate monitoring.
A resident at an LTC facility fell and fractured their femur after Maintenance Worker 1 mopped the floor without notifying the resident or placing a wet floor sign. The resident, who had a history of falls and required assistance with mobility, slipped on the wet floor while attempting to go to the bathroom. The facility's policies on fall prevention were not followed, leading to the incident.
A facility failed to report an alleged abuse incident to CDPH within the required two-hour timeframe. The incident involved a resident with dementia hitting another resident. Although the incident was reported internally, it was not communicated to CDPH promptly, as confirmed by staff interviews and facility policy.
The facility failed to ensure kitchen staff were properly trained and evaluated for competency, leading to incorrect sanitizing procedures and inconsistent adherence to the policy on residents bringing food from home. This could result in ineffective sanitization and increased risk of foodborne illnesses for residents.
The facility failed to ensure safe and sanitary food storage and preparation practices, including improper food labeling, poor air circulation in freezers, and unclean equipment. Observations revealed unlabeled, undated, and expired food, dirty storage areas, and cracked resident trays. Staff interviews confirmed the importance of proper food handling to prevent illness, but the facility did not adhere to its policies, resulting in multiple deficiencies.
The facility failed to properly dispose of garbage and refuse, with one black dumpster and one blue dumpster left uncovered and overflowing. The trash area was not maintained, with soiled gloves and debris scattered around. The Maintenance Supervisor confirmed the bins were not closed properly, potentially attracting pests and leading to cross-contamination.
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of cockroaches in the kitchen. Observations and interviews with Registered Dietitians confirmed the presence of pests, and a review of pest control service reports indicated multiple cockroach findings and recommended intensive treatment. The facility's policy on pest control was not effectively implemented, posing a risk of food contamination and potential foodborne illnesses for the residents.
A resident with dementia and adult failure to thrive was given Aspirin without a specified dosage due to an incomplete physician's order. The LVN administered 81 mg by default, and the DON confirmed that the pharmacist did not complete the Medication Regimen Review. The facility failed to clarify the correct dosage with the physician until later, violating their medication labeling policy.
The facility failed to meet professional standards of quality for a resident with dementia and hypertension by not specifying the dosage in a physician's order for Aspirin. Staff administered 81 mg by default, which could lead to incorrect dosing. Both LVN 1 and the DON confirmed that the order should have included the dosage.
The facility failed to properly store and dispose of medications according to their policies. An LVN was unable to identify unlabelled pills in a disposal container, and 34 multi-use medication containers lacked open dates. Both the LVN and DON were unaware of the facility's policies regarding medication disposal and labeling.
A resident with severe cognitive impairment was found with unauthorized medications at their bedside. The resident had not been assessed for self-administration of medications, and facility staff were unaware of the medications' presence. This failure posed a risk of harm due to potential drug interactions and allergic reactions.
The facility failed to provide advanced healthcare directive information to the responsible parties of two residents, violating their rights. Both residents lacked the capacity to make medical decisions, and the facility did not ensure that their healthcare wishes were documented, potentially leading to situations where their wishes might not be honored.
The facility failed to provide a safe environment for a resident with dementia by not securing or covering multiple exposed sheathed wires and connectors on the bed side rail. The Maintenance Supervisor confirmed the danger, and the Director of Nursing acknowledged the issue, stating that CNAs should report such hazards. The facility's policy on avoiding environmental hazards was not followed in this case.
A resident with an anxiety disorder and moderately intact cognition was found with elevated bed side rails used as physical restraints without proper assessment, consent, or a care plan. Staff confirmed the absence of an order for restraints, and the Director of Nursing acknowledged the potential harm and rights violation.
A facility failed to obtain a physician's order for a low air loss mattress (LALM) for a resident with Type 2 Diabetes, mobility issues, and muscle weakness. The resident, who lacked decision-making capacity, was observed on a LALM without a corresponding order. Both an LVN and the DON confirmed that this practice could lead to inappropriate treatments and interventions, potentially worsening the resident's condition.
The facility failed to develop and implement care plans for a resident's low air loss mattress and another resident's full bed length side rails. Both the LVN and DON confirmed the absence of these care plans, which hindered the ability to monitor the effectiveness of the interventions.
The facility failed to provide adequate assistance with ADLs for two residents, resulting in missed showers and feelings of anger and uncleanliness. Despite requests, staff were too busy to assist, leading to multiple missed hygiene care days.
The facility failed to ensure that the settings for a Low Air Loss Mattress (LALM) were correct and appropriate to the weight of a resident. The resident, who required assistance for daily activities and was at risk for pressure sores, had their LALM set to 280 pounds while their documented weight was 184 pounds. This discrepancy was confirmed by the RNS and DON, who acknowledged that incorrect settings could lead to the development or worsening of pressure sores.
The facility failed to change the tube feeding formula for a resident within the 48-hour timeframe as required by both the manufacturer's instructions and the facility's policy. This oversight was confirmed by both an LVN and the DON, and it posed potential health risks for the resident, who had multiple medical conditions and was dependent on staff for daily care.
The facility failed to ensure that five staff members were assessed for competency upon hire and annually. Interviews and record reviews revealed that several staff members, including a Treatment Nurse and a Registered Nurse Supervisor, had not completed annual skills competency training. The facility's policy requires annual competency assessments, but this was not adhered to, potentially leading to inadequate or delayed resident care.
The facility failed to label 34 multi-use open medication containers in Medication Cart B, #2, with an open-for-use date as required by policy. Both an LVN and the DON were unaware of the labeling policy.
The facility failed to provide at least 80 square feet per resident in 52 of 84 resident rooms, as required by federal regulations. Despite the deficiency, resident interviews indicated no concerns, and observations showed ample space for movement and care. The facility had submitted a Request for Room Size Waiver, arguing that the room sizes did not impede resident care or safety.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering a one-time dose of Ativan, an anti-anxiety medication, to a resident. The resident, an elderly female with multiple diagnoses including diabetes, COPD, hypertension, and a history of anxiety, experienced a change in condition characterized by agitation, refusal of medication and hospital transfer, and vital sign abnormalities. The nurse practitioner ordered Ativan to manage the resident's acute behavioral distress and facilitate safe transport to the hospital. However, there was no documentation or recollection by the LVN that informed consent was obtained before administering the medication, despite the resident being described as self-responsible and able to make her own decisions. Facility policy requires that informed consent be obtained by the prescriber prior to the initiation of any psychotropic medication, including anxiolytics such as Ativan. The DON confirmed that consent is required before administering such medications. The lack of documented informed consent prior to giving Ativan constituted a failure to ensure the resident's right to make an informed decision about her care, as required by facility policy and applicable regulations.
Failure to Develop Comprehensive Fall Prevention Plan and Complete Accurate Fall Risk Assessment
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan and complete an accurate initial Fall Risk Evaluation for a resident identified as high risk for falls. The resident, who had a history of falling, hypertension, depression, impaired cognition, and required substantial assistance with activities of daily living, was admitted and readmitted to the facility. The Fall Risk Evaluation form for this resident was incomplete, with several key assessment questions left blank, resulting in an inaccurate fall risk score. The care plan noted the resident was at high risk for falls but only included a general intervention for staff to observe the resident frequently, without specifying detailed or individualized interventions to prevent repeated falls. Staff interviews revealed that the resident was confused, incontinent, had an unsteady gait, and was known to attempt to get up independently despite being unsafe to do so. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) acknowledged that the resident was a fall risk and described facility practices such as using tab alarms and rounding every two hours for fall prevention. However, the resident did not have a tab alarm in place, and there was no documented evidence that two-hourly rounds or other specific interventions were consistently performed for this resident. The facility's own policies required monitoring and documentation of interventions for fall risk residents, but these were not followed or documented in this case. As a result of these deficiencies, the resident was found on the floor in pain after a fall, which led to a right hip fracture requiring hospitalization and surgery. The incomplete assessment and lack of individualized, documented interventions contributed to the failure to prevent the fall and subsequent injury. Facility leadership, including the MDS Nurse and DON, confirmed that the assessment was incomplete and that missing information could lead to inaccurate care planning and potential harm.
Failure to Arrange Appropriate Transportation Resulting in Missed Medical Appointments
Penalty
Summary
The facility failed to ensure proper transportation arrangements for a resident with significant mobility and medical needs, resulting in missed doctor's appointments and blood work. The resident, who had diagnoses including acute embolism and thrombosis, peripheral vascular disease, schizophrenia, and HIV, required either a bariatric van, gurney, or geriatric chair for safe transport. Documentation showed that the resident was dependent on staff for transfers and required maximal assistance for mobility. On multiple occasions, the facility arranged transportation that did not meet the resident's needs, such as sending a non-bariatric van or a non-gurney vehicle, leading to the cancellation of scheduled medical appointments. Interviews with the resident and multiple staff members, including an LVN, Social Services director, Director of Staffing Development, and DON, confirmed that the resident missed at least two doctor's appointments and associated blood work due to inappropriate transportation being provided. Staff acknowledged awareness of the resident's specific transport requirements and the repeated issue of the transportation company sending vehicles that could not accommodate these needs. The facility's policy indicated that social services would assist residents in obtaining transportation, but this was not effectively implemented for this resident, resulting in the deficiency.
Failure to Ensure Proper Food Labeling and Hand Hygiene in Dietary Department
Penalty
Summary
Kitchen staff failed to follow proper food labeling and handling procedures, as observed during a survey. Cilantro, lettuce, and carrots stored in the refrigerator were not labeled with delivery or use-by dates, and some vegetables were found to be brown and wilted. The Dietary Supervisor confirmed that the produce had not been labeled upon receipt and acknowledged that spoiled items needed to be discarded. Additionally, a bin containing various vegetables lacked any labeling, and some items inside were visibly spoiled. During the same observation, one out of three dietary staff members did not wash their hands upon entering the kitchen, after donning a hairnet, and before handling food in the refrigerator. The Dietary Supervisor admitted that handwashing should have occurred before entering the kitchen and touching the refrigerator. Review of facility policies confirmed that all food items should be properly covered, dated, and labeled, and that staff are required to follow safe food handling practices to prevent foodborne illness.
Failure to Ensure Dignity and Respect in Resident Communication
Penalty
Summary
Two residents with cognitive capacity and language preferences other than English were not treated with dignity and respect by a medication nurse during communication. One resident, who required substantial assistance with activities of daily living and had a history of hypertension, diabetes, arthritis, and above-the-knee amputation, reported being spoken to disrespectfully and with an attitude by the evening medication nurse. The resident also stated that the nurse did not attempt to communicate in a language the resident could understand or take steps to facilitate effective communication. Another resident, who was cognitively intact and had diagnoses including hemiplegia, hemiparesis, hypertension, and hyperlipidemia, witnessed the same nurse arguing with the first resident and attempted to assist with communication due to his partial understanding of English. His efforts were dismissed by the nurse, who told him to mind his own business. The Director of Nursing acknowledged that miscommunications could lead to frustration and suggested that an intervention would be to obtain another staff member to interpret for the residents. The facility's policy requires employees to treat all residents with kindness, respect, and dignity, which was not followed in these instances.
Failure to Communicate with Residents in Preferred Language
Penalty
Summary
The facility failed to ensure that two residents were communicated with in their preferred language, as required by their care needs and facility policy. Both residents were cognitively intact and had documented language preferences other than English in their Minimum Data Set (MDS) assessments. Despite this, interviews revealed that one resident experienced ongoing difficulty communicating with medication nurses, and no alternative communication methods or interpretation services were offered to assist him in understanding his care. The other resident also had a language preference documented but there was no evidence that this need was accommodated. The Director of Nursing acknowledged during an interview that lack of communication in a resident's preferred language could lead to frustration and that an appropriate intervention would be to obtain another staff member to interpret. The facility's policy on accommodating communication deficits stated that communication needs would be identified and appropriate interventions, including care planning, would be developed to meet those needs. However, the facility did not implement these interventions for the two residents, resulting in their communication needs not being met.
Failure to Provide and Communicate Ordered Pain Management
Penalty
Summary
A resident with a history of hypertension, type 2 diabetes, arthritis, and an above-the-knee amputation was admitted to the facility and was cognitively intact, with a language preference other than English. The resident was prescribed ibuprofen for mild pain and Percocet for moderate to severe pain, as needed. However, the resident reported not receiving the previously ordered pain medications and was only receiving Tylenol for pain. The resident expressed confusion about which pain medications were currently ordered and stated that information about pain medications was not communicated in a language he could understand. Record review showed that the resident had not received Percocet after a certain date, despite the orders still being active and available for administration if pain was present. The Medication Administration Record confirmed that only ibuprofen had been administered in recent days. The Director of Nursing verified that the Percocet orders were still active and could have been given. The facility's policy required prompt response to reports of pain and effective communication, but these were not followed, resulting in the resident not receiving appropriate pain management or education about his medications.
Failure to Maintain Clean, Safe, and Functional Environment Due to Leaking Pipes and Cockroach Infestation
Penalty
Summary
The facility failed to maintain a clean, safe, and functional environment for all 92 residents, as evidenced by multiple observations and interviews. In Medication Room A, a leaking pipe was found under the sink cabinet, with a grey wash basin placed to catch the water. The Registered Nurse Supervisor (RNS) was unaware of the leak, and no staff or the Maintenance Supervisor (MS) had reported it. The RNS acknowledged that unrepaired leaks could lead to mold, which could make residents and staff ill. In Medication Room B, multiple dead cockroaches were observed under the sink cabinet. The RNS, as well as the Director of Nursing (DON) and Administrator, confirmed that this infestation had not been reported to them. The Administrator stated that the MS is responsible for cleaning under sink cabinets and fixing leaks, and that pest control should be notified immediately in the event of an infestation. Pest control service records showed no indication that Medication Room B had been treated for cockroaches, despite the facility's policy of bi-monthly pest control visits. Interviews with the MS revealed that maintenance issues are to be logged at the nurses' stations and that he checks these logs daily. The MS stated he had last cleaned under the sink in station B two weeks prior and had not received any reports about cockroaches. He also confirmed he had no professional plumbing training and had not repaired the leaking pipe in Medication Room A. Facility policies reviewed indicated that the MS is responsible for maintaining plumbing and ensuring a clean, pest-free environment, but these responsibilities were not fulfilled as required.
Failure to Follow Standardized Recipe for Therapeutic Diets
Penalty
Summary
A deficiency occurred when a cook (CK) failed to follow the standardized recipe for Szechwan pork during lunch preparation. The recipe, as reviewed, did not include the addition of salt, pepper, or extra garlic powder. However, during observation, the CK admitted to adding these ingredients, specifically stating that salt was added to enhance the flavor of the pork. The CK acknowledged that the facility recipe should be followed and recognized that adding salt could negatively impact residents, particularly those with hypertension. Interviews with the registered dietician (RD) and the director of nursing (DON) confirmed that recipes are designed to meet therapeutic dietary needs and should be strictly followed, especially for residents with specific medical conditions such as hypertension. The facility's policy also requires that menus be prepared as written using standardized recipes, and that dietary staff are responsible for adhering to these guidelines to ensure nutritional adequacy and compliance with physician orders.
Failure to Discard Outdated Jelly in Refrigerator
Penalty
Summary
Surveyors observed that a container of jelly in one of the facility's refrigerators was labeled with an open date of 4/11/2024, which was beyond the 30-day period allowed for opened food items according to the registered dietician. The registered dietician confirmed during the observation that food items opened and stored in the refrigerator should be discarded after 30 days, and the jelly should not have remained in the refrigerator past this timeframe. The Director of Nursing also stated in an interview that food with a label date of 4/11/2024, whether open or closed, should not be present in the refrigerator due to potential harm. Facility policies reviewed indicated that food and supplies must be stored properly and safely, and that opened jellies, when refrigerated, are allowed for up to 6 months, which conflicted with the staff's statements. The presence of the outdated jelly in the refrigerator demonstrated a failure to follow safe food handling practices as observed and confirmed by staff.
Failure to Maintain Sanitary Environment in Resident Bathroom
Penalty
Summary
The facility failed to maintain a sanitary environment in one of its resident bathrooms by not adhering to established infection control measures. During a facility tour, surveyors observed three visibly soiled towels hanging on the towel rack, as well as a used coffee cup with residue and a water pitcher and cup placed on a shelf above the bathroom sink. These items were not supposed to be present in the bathroom according to infection control protocols. Certified Nurse Assistant (CNA) 1 confirmed that the dirty towels, coffee cup, and water pitcher should not be in the bathroom due to infection control concerns, but was unaware of who left them there. Further interviews with the infection prevention nurse (IPN) and the Director of Nursing (DON) confirmed that the presence of dirty towels, cups, and water pitchers in the bathroom constitutes an infection control issue, as it can expose residents to disease-causing microorganisms. A review of the facility's infection prevention and control policy indicated that the program is designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections. The policy applies to all staff, who are trained on these procedures upon hire and periodically thereafter.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in 20 out of 40 resident rooms, as mandated by federal regulations. Specifically, the rooms in question were designed for three residents each but measured less than the required 240 square feet, with individual room sizes ranging from approximately 201 to 236 square feet. This deficiency was identified through a review of facility records, including a waiver request letter submitted by the Administrator, which acknowledged the shortfall in room sizes. The federal regulation requires at least 80 square feet per resident in multiple occupancy rooms, and the rooms listed did not meet this standard. During observations conducted over several days, residents were seen to have sufficient space to move about, and there was adequate room for necessary furniture and care equipment. Additionally, during a resident council meeting, several residents expressed that their room sizes were adequate. Despite these observations and resident statements, the facility's failure to meet the minimum square footage requirement constitutes a deficiency as per federal standards.
Inaccurate MDS Assessment of Insulin Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment entries accurately reflected a resident's insulin status. Specifically, the MDS for a resident, completed on 2/19/2025, indicated that the resident received one injection of insulin during the seven-day look-back period. However, a review of the resident's medical chart and interview with the MDS Coordinator revealed that the insulin order had been discontinued on 2/6/2025, prior to the look-back period. This resulted in inaccurate documentation on the MDS regarding the resident's insulin administration. The resident involved had a medical history including congestive heart failure, hypertension, and diabetes mellitus, and was dependent on staff for several activities of daily living. Both the MDS Coordinator and the Director of Nursing confirmed that the MDS is used to guide care planning and that inaccurate entries could lead to an incorrect care plan. The facility's policy required comprehensive assessments to be conducted according to established criteria and timeframes, but this was not followed in this instance.
Failure to Assist Resident in Obtaining Dentures After Loss
Penalty
Summary
The facility failed to assist a resident in obtaining dentures after the resident's dentures went missing. The resident, who had a history of diabetes mellitus, muscle wasting, atrophy, and anemia, was admitted and later readmitted to the facility. Documentation showed the resident was edentulous and at risk for poor oral intake, with care plans indicating the need for dental assessment and referral as well as good oral hygiene. Despite a dental consult noting the resident's interest in dentures and an order for dental consult and treatment as needed, the resident reported that her request for dentures had not been addressed and that her dentures had been missing for a long time. Staff interviews confirmed the resident no longer had dentures and had difficulty eating certain foods, rarely finishing her meals. The facility's policy required referral for dental services within three days if dentures were lost, or documentation of actions taken and reasons for delay. However, there was no evidence that the facility made a timely referral or provided adequate follow-up to ensure the resident could eat and drink adequately while awaiting dental services. The Social Services Director acknowledged the resident's request for dentures and the potential for weight loss due to the lack of dentures. The DON confirmed that staff are responsible for following up on such requests and recognized the impact of not having dentures on chewing and weight maintenance.
Inadequate PPE Use During Influenza Outbreak
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program during an influenza outbreak. Specifically, a certified nursing assistant (CNA) entered an isolation room without donning the required personal protective equipment (PPE), which included a gown, mask, and face shield. The CNA only wore gloves when entering the room of a resident who was on droplet precautions due to exposure to respiratory syncytial virus (RSV). The CNA admitted to forgetting to put on the full PPE because he was only assisting the resident with water and the resident was not his assigned responsibility. The resident in question had a severely impaired cognitive function and was unable to communicate needs or make decisions regarding care. The facility's policy required staff to don and doff PPE properly before entering and exiting isolation rooms, as reiterated by the RN Supervisor, Director of Staff Development, and Infection Preventionist during interviews. Despite the facility's policy and training efforts, the CNA's failure to adhere to the protocol represented a break in infection control, potentially increasing the risk of spreading influenza within the facility.
Failure to Ensure Proper Blood Sugar Monitoring for NPO Resident
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube feeding and an NPO order had appropriate medical orders for fingerstick blood sugar checks every six hours. The resident, who was admitted with diagnoses including type two diabetes, hypertension, heart failure, gastrostomy, dysphagia, and muscle weakness, was dependent on staff for various activities of daily living due to severely impaired cognition. Despite the resident's condition and care plan indicating the need for Accu-checks as ordered, there was no specific order for NPO status or separate fingerstick blood glucose checks apart from insulin orders. During interviews and record reviews, it was confirmed by both an LVN and an RN Supervisor that the necessary orders were not present in the resident's chart. The RN Supervisor acknowledged that blood sugar checks should occur every six hours for an NPO resident, yet the existing orders only specified checks before meals and at bedtime. This oversight had the potential to result in inaccurate blood sugar monitoring for the resident, impacting the care and services provided.
Failure to Prevent Fall Due to Wet Floor
Penalty
Summary
The facility failed to provide a safe environment to prevent falls for a resident, identified as Resident 1, who slipped and fell due to a wet floor in their room. Maintenance Worker 1 (MW 1) mopped the floor in Resident 1's room but did not notify the resident or their roommate that the floor was wet. Additionally, MW 1 failed to place a wet floor sign to alert the residents of the hazard. As a result, Resident 1, who was attempting to go to the bathroom, slipped on the wet floor and fell, suffering severe pain in the left knee. Resident 1 had a history of falls and was at risk for falls due to general weakness, a history of left ankle fracture, osteopenia, and muscle weakness. The resident was admitted to the facility for physical and occupational therapy and required assistance with mobility, using a walker for support. At the time of the incident, Resident 1 was alert and oriented but had impaired vision and required assistance with daily activities. The fall resulted in a left femur fracture, and the resident was transferred to a hospital for treatment, where they underwent surgery for the fracture. Interviews with staff and the resident's roommate confirmed that MW 1 did not inform them of the wet floor, nor was a wet floor sign placed. The facility's policy and procedures require staff to identify and mitigate fall risks, including wet floors, but these protocols were not followed. The Director of Rehabilitation and other staff acknowledged that a wet floor is a fall risk, and the failure to notify residents and place a warning sign contributed to the incident.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. This deficiency involved an incident between two residents, where one resident, diagnosed with dementia and lacking decision-making capacity, allegedly hit another resident on the arm after attempting to unplug their television. The resident who was hit did not require pain medication and expressed no fear of remaining in the facility, acknowledging the other resident's mental state. The incident was reported internally within the facility, with the Certified Nursing Assistant informing the Administrator, who then informed the Director of Staff Development. However, the Administrator did not report the incident to CDPH within the mandated two-hour period. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed the understanding that such incidents should be reported promptly to CDPH. The facility's policy, revised in March 2023, also stipulates that allegations involving abuse or serious bodily injury must be reported within two hours.
Inadequate Training and Policy Adherence in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency skills. One dietary aide did not follow the manufacturer's guidelines when checking the concentration of the QUAT sanitizing solution. The aide dipped the test strip for only eight seconds instead of the required ten seconds and did not check the water temperature, which is necessary for accurate testing. The aide admitted to not being trained to test the water temperature and was unaware of the correct procedure. This failure to follow guidelines could result in ineffective sanitization of kitchen surfaces and dishes, potentially leading to foodborne illnesses for the residents. Additionally, staff members were not able to consistently verbalize the facility's policy regarding residents bringing food from home. Interviews with various staff members, including a Licensed Vocational Nurse, Activities Assistant, Activities Supervisor, and Director of Staff Development, revealed discrepancies in their understanding of how long food from outside sources could be stored. The staff provided conflicting information, ranging from one to three days, and some were unsure of the exact policy. This inconsistency in following the food storage policy could lead to residents consuming spoiled food, increasing the risk of foodborne illnesses. The facility's policy and procedures on food from outside sources were reviewed, indicating that while outside food is discouraged, it is allowed under certain conditions. The policy requires that the charge nurse be notified and that the food be checked to ensure it aligns with the resident's prescribed diet. However, the staff's lack of consistent knowledge and adherence to this policy highlights a significant gap in training and communication, which could compromise the safety and well-being of the residents.
Facility Fails to Ensure Safe and Sanitary Food Storage and Preparation
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. Observations revealed improper storage of food, including unlabeled, undated pasta, ranch dressing, and expired cheese. Additionally, bacon slices were found uncovered, unlabeled, and undated. The resident's refrigerator contained unlabeled, undated, and expired food, along with staff's parmesan cheese, drink, and Italian dressing. Interviews with staff confirmed the importance of labeling and dating food to prevent residents from consuming expired food, which could lead to illness. The facility also exhibited poor air circulation in Freezers 3 and 4, which were observed to be full of food. The Registered Dietitian acknowledged the overcrowding and the need for proper air circulation to maintain food safety. Furthermore, equipment cleanliness was compromised, with dirt and debris found in Freezer 3, dust buildup in Refrigerator 2's vent, and black dirt debris in Refrigerator 1. The dry storage area also had dust buildup, dirty cans, and food debris on the floor. The ice machine, located outside, had significant dirt buildup on both internal and external parts, raising concerns about cross-contamination and infection. Additionally, two dented cans were stored with undented cans in the dry storage area, and seventeen cracked and chipped resident trays were found in use. Staff interviews highlighted the potential risks of using dented cans and damaged trays, which could lead to bacterial growth and cross-contamination. The facility's policies and procedures were reviewed, indicating the need for proper labeling, dating, and cleanliness of food storage areas and equipment. However, the facility failed to adhere to these guidelines, resulting in multiple deficiencies that could potentially harm the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly, as observed during a survey. One of two black dumpsters and one blue dumpster were not covered for an unknown amount of time. The blue dumpster was overflowing with cardboard boxes. The trash area was not maintained, with soiled gloves and other debris scattered around. The Maintenance Supervisor confirmed that the trash bins were not closed properly and that the area was not clean, which could attract pests and lead to cross-contamination and potential illness among residents. The facility's policies and procedures for waste control and disposal, as well as pest control, were not followed. The policies required that trash bins be covered at all times, outside garbage bins be kept closed, and surrounding areas be kept clean. Additionally, cardboard boxes were to be broken down and disposed of timely. The Food Code 2017 also mandates that waste handling units for refuse be kept covered with tight-fitting lids or doors if kept outside the food establishment. These lapses in following established protocols contributed to the deficiency observed by the surveyors.
Sanitary Conditions in Food Services Department Not Maintained
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of cockroaches in the kitchen. During an observation and interview with the Registered Dietitian (RD 1), a dead cockroach and a live baby cockroach were found on the floor underneath the dishwashing sink. RD 1 acknowledged the presence of the insects and stated that the kitchen should be free of pests for food safety. Another observation and interview with Registered Dietitian (RD 2) confirmed the presence of pests, and RD 2 mentioned that a pest control service had recently treated the facility, but no cockroaches were found during their inspection. However, a review of the pest control service report from 3/28/2024 indicated that 12 cockroaches were found in the kitchen, and intensive roach treatment was recommended to prevent a kitchen shutdown. The report also recommended improving sanitation and keeping doors closed to prevent pest entry. Further inspection revealed a half-inch gap in the screen door leading to the trash area, which could allow pests to enter. The Administrator (ADM) reviewed a video clip of a cockroach in the dishwashing area and confirmed the presence of pests. ADM stated that the pest control service would return to inspect and treat the kitchen. A subsequent pest control service report from 4/3/2024 indicated that 30 German cockroaches were found in the kitchen, and intensive treatment was performed. The facility's policy on pest control, revised on 2/20/2024, stated that the facility should maintain an effective pest control program to keep the building free of insects and rodents. Despite these measures, the presence of cockroaches in the kitchen posed a risk of food contamination and potential foodborne illnesses for the residents.
Failure to Ensure Complete Medication Order for Resident
Penalty
Summary
The facility failed to ensure that Resident 3 was free from significant medication errors. Resident 3, who had diagnoses including adult failure to thrive and dementia, was readmitted to the facility with a physician's order for chewable Aspirin to be administered via G-tube once daily for cardiac prophylaxis. However, the order did not specify the dosage. During a medication administration observation, LVN 1 revealed that the computer system only indicated 'chewable aspirin' without a dosage, leading them to administer 81 mg by default. LVN 1 acknowledged that a complete medication order should include the name, dosage, and route of administration, and that an incomplete order could result in ineffective medication therapy or an overdose, which could be fatal to the resident. The Director of Nursing (DON) confirmed that the pharmacist did not complete the Medication Regimen Review (MRR) for the Aspirin, and the facility failed to clarify the correct dosage with Resident 3's physician until the day of the interview. The facility's policy on medication labeling, revised recently, mandates that all medications be properly labeled according to state and federal guidelines. The failure to ensure a complete medication order for Resident 3's Aspirin had the potential to lead to significant medication errors, including overdose or underdose, which could be fatal.
Failure to Specify Dosage in Medication Order
Penalty
Summary
The facility failed to meet professional standards of quality for Resident 3, who was admitted with medical diagnoses including adult failure to thrive, dementia, and hypertension. The deficiency was identified when it was observed that the physician's order for Aspirin, dated 12/29/2023, did not specify the dosage. During an interview, LVN 1 admitted that the computer system only indicated 'chewable aspirin' without a dosage, leading staff to administer 81 mg by default. LVN 1 acknowledged that a complete medication order should include the name of the medication, dosage, and route of administration. The Director of Nursing (DON) confirmed that the aspirin order should have included the dosage and that the absence of this information could result in incorrect dosing. The review of Resident 3's Minimum Data Set (MDS) indicated that the resident had impaired cognition and was dependent on staff for various activities, including feeding and personal hygiene. The facility's Medication Pass Tips, revised on 2/20/2024, emphasized the importance of the 'ten rights' of medication administration, including the right dose. The failure to include the correct dosage in the medication order had the potential to cause underdosing, overdosing, and hospitalization, as confirmed by both LVN 1 and the DON during their interviews.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and disposed of according to their policies and procedures. During an observation of Medication Cart B, an undated clear plastic container labeled 'Disposal Medication All Refusal' was found to contain 22 unidentifiable pills inside and four unidentifiable pills outside the container. The Licensed Vocational Nurse (LVN) could not identify the pills or determine if they were controlled substances. The Director of Nursing (DON) confirmed that refused medications should be discarded immediately in a locked storage room with a solution called a drug buster, but was unable to explain the consequences of not doing so. The facility's policy requires controlled medications to be destroyed in the presence of two licensed nurses and documented accordingly, which was not followed in this instance. Additionally, 34 out of 36 multi-use medication containers in Medication Cart B were found to be in use without an open date, contrary to the facility's policy. The LVN was unaware of the policy for labeling multi-use medication containers, despite being employed at the facility since July 2023. The DON also did not know that multi-use open medication containers needed to have an open date and was unfamiliar with the facility's policy on labeling open medications. The facility's policy mandates that the open date be labeled on medication containers once they are opened, which was not adhered to in this case.
Failure to Prevent Unauthorized Medication Access
Penalty
Summary
The facility failed to ensure that medications were not left with a resident who was not capable of self-administering them. Resident 77, who had severe cognitive impairment and required assistance with daily activities, was found with three pills on their bedside drawer. The resident stated that a friend had brought the medications because the facility staff were not responding to requests for headache medication. The resident's medication administration record indicated an order for Norco, but there was no documented evidence that the resident was assessed to self-administer medication. During interviews, the Licensed Vocational Nurse and the Director of Nursing confirmed that Resident 77 did not have an order to self-administer medications and should not have had any medications at bedside. The facility's policy requires an interdisciplinary team assessment to determine a resident's ability to self-administer medications, which had not been conducted for Resident 77. The Director of Nursing acknowledged that the presence of non-prescribed medications posed a risk for potential harm, including drug interactions and allergic reactions.
Failure to Provide Advanced Healthcare Directive Information
Penalty
Summary
The facility failed to ensure that advanced healthcare directive information was provided to the responsible parties (RPs) of two residents, resulting in a violation of their rights. Resident 1, who was diagnosed with Alzheimer's disease, schizophrenia, and hypertension, did not have the capacity to make medical decisions. Despite this, the facility did not contact Resident 1's power of attorney to complete the advanced directive acknowledgment (ADA) form. The Social Services Director (SSD) admitted that the ADA form was not completed and only sent an email regarding it on the day of the interview. This oversight meant that Resident 1's healthcare wishes were not documented in the chart, potentially leading to life-threatening situations where the resident's wishes might not be honored. Similarly, Resident 3, who was diagnosed with adult failure to thrive, dementia, and hypertension, also did not have the capacity to make medical decisions. The SSD confirmed that Resident 3's ADA form was not completed by the RP, which could result in the resident's healthcare wishes not being followed. The Director of Nursing (DON) emphasized the importance of completing the ADA form upon admission to ensure that the facility is aware of and can honor the residents' healthcare wishes. The facility's policy and procedures require compliance with healthcare decisions made by authorized persons, but this was not adhered to in these cases.
Failure to Secure Exposed Wires on Bed Side Rail
Penalty
Summary
The facility failed to provide a safe environment for Resident 29 by not securing or covering multiple exposed sheathed wires and connectors on the bed side rail. Resident 29, who was admitted with diagnoses including unspecified dementia, psychotic disturbance, and anxiety, did not have the capacity to understand and make decisions. The resident required assistance from staff for daily activities and exhibited behavioral symptoms of dementia such as anxiety and restlessness. During an observation, it was noted that the bed side rail had multiple exposed wires, which posed a risk of injury or harm to the resident. The Maintenance Supervisor confirmed that there was no request order for Resident 29's bed and acknowledged the danger posed by the exposed wires. The Director of Nursing stated that CNAs are responsible for reporting bed malfunctions to the maintenance supervisor and agreed that it was unacceptable for a resident to be on a bed with exposed wires. The facility's policy on avoiding environmental hazards indicated that items posing harm to residents should be removed, and direct caregivers should check the resident's unit to identify and remove such items. However, this policy was not followed in the case of Resident 29.
Inappropriate Use of Physical Restraints on Resident
Penalty
Summary
The facility failed to ensure that Resident 288 was free from physical restraints. Resident 288, who was admitted with an anxiety disorder and had moderately intact cognition, was observed with bilateral full-size bed side rails elevated. Certified Nursing Attendant 1 confirmed that the side rails were used to prevent the resident from falling, despite acknowledging the risk of the resident getting tangled in the rails. Licensed Vocational Nurse 2 and Licensed Vocational Nurse 3 both confirmed that there was no order for restraints in the resident's chart, and that the use of side rails without proper assessment, consent, or a care plan could potentially harm the resident. The Director of Nursing also confirmed that the side rails were elevated without an order or consent, emphasizing that this practice could disrespect the resident's rights and potentially cause harm. A review of the facility's policy on physical restraints indicated that any use of mechanical devices restricting freedom of movement requires an order from the attending physician, informed consent, and a detailed plan of care. The facility's failure to adhere to these policies resulted in the inappropriate use of physical restraints on Resident 288.
Failure to Obtain Physician's Order for Low Air Loss Mattress
Penalty
Summary
The facility failed to obtain a physician's order for a low air loss mattress (LALM) for a resident who was admitted with diagnoses including Type 2 Diabetes, abnormalities of mobility, and muscle weakness. The resident, who lacked the capacity to understand and make decisions, was observed in bed on a LALM without a corresponding physician's order. This was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the absence of a physician's order could lead to inappropriate treatments and interventions, potentially worsening the resident's skin condition. The Director of Nursing (DON) confirmed that an order is required for the use of an air mattress and that it is not professional nursing practice to implement treatments without a physician's order. The facility's policy and procedures, dated 2/20/2024, also indicated that physician's orders must be obtained prior to the initiation of any medication or treatment. This deficiency had the potential to harm the resident by not providing appropriate treatment and interventions.
Failure to Develop and Implement Care Plans for Specialized Equipment
Penalty
Summary
The facility failed to develop and implement a care plan for Resident 9's low air loss mattress (LALM) and Resident 288's full bed length side rails. Resident 9, who was admitted with diagnoses including Type 2 Diabetes, abnormalities of mobility, and muscle weakness, did not have a care plan for the LALM despite requiring assistance for daily activities and lacking the capacity to make decisions. During an observation, Resident 9 was found lying on a LALM set to 280 pounds, and both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed the absence of a care plan for the LALM, which hindered the ability to monitor the effectiveness of the intervention. Similarly, Resident 288, admitted with an anxiety disorder and requiring assistance for daily activities, did not have a care plan for the full bed length side rails observed in their room. The DON confirmed that no care plan for restraints was found in Resident 288's chart or electronic records. The facility's policy and procedures indicated that care plans should be reassessed and updated to reflect the current status of residents, but this was not adhered to in these cases.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, resulting in feelings of anger and potential health risks. Resident 54, who has muscle weakness and Type 2 diabetes, was observed with unshaven facial hair and reported not receiving assistance with shaving or showers as scheduled. Despite requesting showers, Resident 54 was told by staff that they did not have time, leading to multiple missed showers and bed baths in March 2024. The resident expressed feelings of anger and uncleanliness due to the lack of proper hygiene care. Resident 6, diagnosed with morbid obesity and muscle weakness, also did not receive scheduled showers. The resident reported not having showered in about two weeks and stated that staff were too busy to assist with showers. Observations confirmed that Resident 6 was not provided with showers on multiple scheduled days in March 2024. The resident expressed frustration and anger over not feeling clean and not preferring bed baths. Interviews with staff, including the Director of Staff Development (DSD), Certified Nurse Assistants (CNAs), and Licensed Vocational Nurses (LVNs), revealed inconsistencies in reporting and providing showers. The facility's policy requires residents to receive showers twice a week unless they refuse or are sick. However, staff failed to adhere to this policy, leading to the identified deficiencies in resident care.
Incorrect LALM Settings for Resident
Penalty
Summary
The facility failed to ensure that the settings for a Low Air Loss Mattress (LALM) were correct and appropriate to the weight of Resident 9. Resident 9, who was admitted with diagnoses including Type 2 Diabetes, abnormalities of mobility, and muscle weakness, did not have the capacity to understand and make decisions. The resident's Minimum Data Set (MDS) indicated that they required assistance from facility staff for eating, hygiene, and toileting. Despite being at risk for developing pressure sores, as indicated in the care plan, there was no specific care plan for the LALM. During an observation, it was found that the LALM was set to 280 pounds, while the resident's documented weight was 184 pounds. This discrepancy was confirmed by the Registered Nurse Supervisor (RNS 1) and the Director of Nursing (DON), who both acknowledged that incorrect settings could lead to the development or worsening of pressure sores. The facility's policy and procedures for pressure-reducing mattresses indicated that the mattress should be set according to the patient's weight or a healthcare professional's suggestion. However, this was not followed in the case of Resident 9. The LALM was not set at the correct weight, which could potentially harm the resident by not providing the correct amount of airflow needed to prevent or treat pressure injuries. The failure to adhere to the correct settings for the LALM and the absence of a specific care plan for its use contributed to the deficiency observed by the surveyors.
Failure to Change Tube Feeding Formula in a Timely Manner
Penalty
Summary
The facility failed to ensure that the tube feeding product/formula was not hanged for more than 48 hours per manufacturer's instructions and facility's policy and procedures for one of the sampled residents. Specifically, Resident 3 had a bottle of Glucerna connected to their gastrostomy tube that was dated 3/26/2024 and had not been changed for 6 days. This was confirmed during an observation and interview with LVN 5, who acknowledged that the feeding bottle should have been changed to prevent infection and potential adverse effects such as an upset stomach. The Director of Nursing also confirmed that tube feeding bottles should be changed every 24 to 48 hours to prevent bacterial growth and associated complications like abdominal pain and loose bowel movements. Resident 3 was admitted to the facility with medical diagnoses including adult failure to thrive, dementia, and hypertension. The resident was dependent on facility staff for feeding, toilet use, oral hygiene, and personal hygiene. The facility's policy and procedures, as well as the manufacturer's instructions for Glucerna, both indicated that the maximum hang time for sterile formula in a closed system is 48 hours. The failure to adhere to these guidelines resulted in the potential for significant health risks for Resident 3.
Failure to Assess Staff Competency
Penalty
Summary
The facility failed to ensure that five out of five staff members were assessed for competency upon hire and annually. This deficiency was identified through interviews and record reviews. The Treatment Nurse, who had been employed for seven years, could not recall the last time they completed an annual skills competency training. Similarly, the Registered Nurse Supervisor, who had worked at the facility only twice, had never completed a competency checklist. The Laundry Aid, who had been employed for several years, also confirmed never having completed an annual skills competency evaluation. The Certified Nurse Assistant 2 was the only staff member who had recently completed an annual skills competency training. The Director of Staff Development and the Director of Nursing confirmed that the facility does not keep employee files for registry nurses and relies on a registry app to verify credentials and competencies, which they could not identify by name. A review of employee files for the Licensed Vocational Nurse/Treatment Nurse, Certified Nurse Assistant 2, Certified Nurse Assistant 3, and the Laundry Aid revealed that none contained a skills competency checklist or a completed staff competency assessment. The facility's policy and procedures, revised in February 2024, indicated that employees should be assessed for competency upon hire and annually. However, the facility failed to adhere to this policy, leading to a potential knowledge, training, and certification deficit among staff, which could result in inadequate or delayed resident care.
Failure to Label Multi-Use Medication Containers
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of residents by not adhering to its policy for labeling multi-use medication containers. During a record review and interview, it was found that 34 multi-use open medication containers in Medication Cart B, #2, were in use without an open-for-use date as required by the facility's policy. Licensed Vocational Nurse 4 (LVN 4) and the Director of Nursing (DON) both admitted to not knowing the facility's policy for labeling these medications. The facility's policy, revised on February 20, 2024, mandates that medications stored in a bottle or container must be labeled with the open date once the container is opened.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 52 of 84 resident rooms, as required by federal regulations. Specifically, rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 116, 118, 120, 121, 122, 134, 137, 138, 141, and 142 were found to be deficient in this regard. The rooms in question had varying sizes but did not meet the minimum square footage requirements for the number of residents they housed. For example, rooms with three beds should have at least 240 square feet, but many of these rooms were significantly smaller. This deficiency was identified through observation, interviews, and record reviews during a recertification survey conducted from April 1 to April 4, 2024. Despite the deficiency, resident interviews indicated no concerns regarding the size of the rooms, and observations showed that residents had ample space to move freely and that there was sufficient space for nursing staff to provide care. The facility had submitted a Request for Room Size Waiver, arguing that the room sizes did not impede resident care or safety. During an interview, the administrator confirmed that a written request for the continued room waiver had been submitted. Measurements taken by the Maintenance Supervisor confirmed the room sizes, and it was noted that the measurements did not include any protrusions from the walls. The report recommends the continuation of the room size waiver.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lotus Care Center | 1.5 mi | ★★★★★ | 14 | 0 |
| Hyde Park Healthcare Center | 1.9 mi | ★★★★★ | 33 | 1 |
| Western Convalescent Hospital | 2.1 mi | ★★★★★ | 38 | 0 |
| Longwood Manor Conv.hospital | 2.3 mi | ★★★★★ | 4 | 0 |
| Crenshaw Nursing Home | 2.3 mi | ★★★★★ | 21 | 0 |
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