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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa Del Sol Post Acute during CMS and state inspections, most recent first.
Incomplete care planning for hearing, therapy, and fungal toenail treatment. A resident with severe cognitive impairment, bilateral hearing loss, and PT/OT needs had no comprehensive care plan addressing hearing aids, hearing deficit, or therapy goals and interventions. Another resident with ESRD, DM, and painful fungal toenails had a care plan that did not reflect the podiatrist’s specific recommendations, and the OSR lacked orders for clotrimazole, a foot pillow, and avoiding barefoot transportation.
Failure to Provide Care-Planned Restorative Nursing Assistance: Two residents did not receive RNA services as directed in their care plans. One resident with a femur fracture, weakness, and limited mobility was scheduled for AROM/AAROM and cycling support but missed multiple weekly RNA services, and another resident with rhabdomyolysis, contractures, and reduced mobility was scheduled for AAROM, knee splints, and PROM but also missed multiple weekly RNA services. The RNS confirmed the missed services, and the DON stated RNA services were important to maintain and improve ROM.
Inaccurate B&B documentation was found for a resident whose record showed no BM for a week, while an LVN recalled the resident having a BM during that timeframe and the resident reported having BM daily or every other day. The DSD stated accurate CNA charting is important because charge nurses rely on it for resident care, and the facility policy required documentation to be accurate, relevant, and complete.
Failure to accommodate a resident’s seating preference in the activity room. A cognitively intact resident with hemiplegia, hemiparesis, contractures, and use of a manual wheelchair stated only one table fit her needs, but when that seat was occupied, the AD told her seating was first come first served and did not assess her needs, explore alternatives, or document her preference. An RNA confirmed only one of six tables was comfortable for the resident, and the DON stated staff should assess and try to meet resident preferences.
A resident with psychosis, depressive disorder, and dementia had an MDS that stated no behavioral symptoms, even though the resident’s monitoring records documented repeated physical aggression and verbal aggression over multiple months. The SSA said she based the MDS on brief observations and did not verify information with nursing staff, while the MDSN confirmed the assessment should have reflected the documented behaviors. The DON stated the MDS must accurately evaluate resident care needs and reflect the care and treatment provided.
A resident with Parkinson’s disease, dementia, syncope, and a history of falls had two unwitnessed falls, including one that caused a fracture and a later fall that caused a cut to the left temple. Staff documented the resident was found on the floor and sent to the hospital, and an RN supervisor stated both events were changes in condition that should have triggered updates to the resident’s fall care plan. The care plan reviewed still addressed repeat falls/injury, but the record showed it was not revised after the second fall.
Failure to provide nail care to a resident with impaired cognition, reduced mobility, and a self-care deficit. The resident was observed with long, dirty fingernails and stated a preference for clean fingernails; a CNA also noted the nails looked dirty and needed to be cleaned or trimmed. The DON stated nails should be kept clean and trimmed for dignity and hygiene, and the facility nail care policy called for routine cleaning, inspection, and trimming as needed.
Failure to Implement Podiatry Foot Care Recommendations: A resident with ESRD, anemia, HF, DM, and impaired cognition had thick, brittle, discolored, painful toenails consistent with a fungal infection. The podiatry evaluation recommended clotrimazole cream, a foot pillow, lotion, appropriate footwear, and avoiding barefoot transportation, but the OSR showed these recommendations were not implemented or ordered. The resident reported pain and embarrassment related to the condition, and the DON and RNS acknowledged the recommendations were not followed through.
Missing Annual CNA Performance Evaluation: The facility failed to document an annual performance review for one CNA. Review of the employee file showed no evaluation for the prior year, and the DSD confirmed the required hire, 90-day, and annual evaluations had not been completed or documented. The DON stated annual evaluations are used to identify strengths and weaknesses and support staff competency, and the facility policy required a formal written evaluation annually.
A resident with nausea and vomiting did not receive ordered ondansetron in a timely manner, with the PRN antiemetic unavailable at first and then not given again when symptoms recurred; the medication was not administered until the next day. In a separate issue, a resident receiving hydrocodone-acetaminophen had a mismatch between the MAR, CDR sheet, and bubble pack at the medication cart because the dose was given but not documented on the narcotic record, and the DON stated the records should all match.
A resident with dementia, GERD, and major depressive disorder was observed at breakfast without the fruit cup and health shake listed on the diet ticket and menu. CNA and DS confirmed the ordered items should have been provided, but they were missing from the tray while the resident was being assisted with eating. The DON stated the diet ticket and menu should be followed for nutrition and health reasons.
Infection Control Lapses With Foam Side Rails and Feces-Soiled Laundry Hamper: Staff observed foam-wrapped side rails in two residents' rooms and used a disinfectant intended for hard, non-porous surfaces on the porous foam. An IP confirmed the product was not appropriate for that material, and the DON stated the rails should be disinfected properly. Staff also found a resident's personal laundry hamper with visible feces on the handle, which a CNA identified as feces and the HS confirmed in a photo review.
A resident with osteogenesis imperfecta, intact cognition, and dependence for ADLs reported right hip pain and stated to PT and nursing staff that hospital nurses had handled her roughly, while her family also reported she had not been handled properly and that her hip was normal before that hospitalization. Nursing assessment later identified a protruding, red, and warm right hip, an X‑ray was ordered, and imaging confirmed an acute displaced proximal femur fracture, after which the resident was transferred to another hospital. Despite the facility’s policy requiring immediate reporting of all abuse allegations and injuries of unknown source, the PT did not report the resident’s statements, and the DON did not notify CDPH of either the abuse allegation or the hip fracture, relying in part on consultant advice that the fracture did not need to be reported.
A resident with dementia, muscle weakness, difficulty walking, incontinence, and a documented high fall risk required one-person assistance with ADLs and had a care plan and IDT recommendations for frequent visual checks and timely assistance after an unwitnessed fall with an elbow skin tear. Despite this, surveyors observed the resident’s room door closed while the resident stood barefoot at the foot of the bed after using the bathroom. The responsible party reported the door was often closed, an LVN acknowledged the door should have been kept open for safety, a CNA admitted he knew the resident was a fall risk but did not communicate the resident’s preference for a closed door to licensed staff, and an RN supervisor reported seeing the resident close her door multiple times without initiating a care plan change, resulting in inadequate visibility and supervision contrary to facility fall prevention and accident policies.
A resident with dementia, polyneuropathies, muscle weakness, difficulty walking, incontinence, and a documented high fall risk had a care plan identifying fall and injury risk with general interventions such as anticipating needs, providing proper footwear, and maintaining a safe environment. After the resident experienced an unwitnessed fall resulting in a left elbow skin tear, an IDT conference documented that the resident was impulsive, had a balance deficit, and attempted to ambulate beyond her capabilities, and recommended frequent visual checks, timely assistance, and reminders about safety precautions. Despite this, the resident’s care plan was not revised to include these updated fall-prevention interventions, and a CNA reported not knowing how often to check on the resident, contrary to facility policies requiring comprehensive, revised care plans and updated fall prevention measures.
Multiple residents and a family member reported repeated loss of labeled clothing, personal items, and a purse with checks, but staff did not document these concerns as grievances, did not enter them into the grievance log, and did not complete required investigations or timely resolutions. Interviews showed that the SSA was unclear on the grievance process, the DON acknowledged that missing property complaints should have been handled as grievances but were not, and the ADM confirmed that Social Services was expected to follow up and reimburse or replace lost items. The facility’s written grievance policy required staff to document verbal or written grievances, forward them to a designated Grievance Official, investigate, keep residents informed, and issue written decisions, yet these steps were not followed for the reported missing property concerns, leaving the issues unaddressed.
A resident with severe cognitive impairment, incontinence, and dependence on staff for ADLs was left undressed from the waist down and lying on urine-soiled linens for several hours, despite care plans requiring frequent incontinence checks, perineal care, and linen changes. The CNA assigned to the resident did not check on her from the start of the shift and acknowledged the resident remained on soiled linens placed by the prior shift. An LVN passed medications without assessing the resident’s condition, did not assist the CNA who was running behind, and did not report delays, resulting in the resident missing a scheduled shower. These actions and inactions occurred despite facility policies on incontinence care, ADLs, resident rights, dignity, and maintaining a clean, sanitary environment.
A resident with generalized muscle weakness, partial foot amputations, UTI, and CKD, who required supervision to touch assistance for ADLs, had a care plan directing that the call light be kept within reach due to fall and injury risk. During observation, the call light was found on the floor out of reach, and the resident reported needing it under the forearm to request help, including assistance to empty a urinal, and having searched for it repeatedly. A CNA stated that, because the resident’s body covered the bed, the call light had been placed on the bedside table earlier in the day, and acknowledged it should have been placed within reach, contrary to facility policy and the DON’s expectation that all residents have accessible call lights checked hourly.
A resident capable of making her own decisions did not have a valid POLST on file, as it was signed by a family member acting only as an interpreter. During a medical emergency, staff were unable to promptly determine the resident's code status and delayed CPR while consulting with family members, despite the presence of a DNR order signed by an unauthorized individual. Paramedics performed CPR upon arrival, but the resident expired.
A resident with dementia and other complex conditions was given Ativan, a psychotropic medication, without a clearly documented indication or consistent monitoring of behaviors and side effects. Facility records and staff interviews revealed that the required manifestations for medication use were not specified in the orders or medical records, and monitoring practices did not meet facility policy requirements.
Staff failed to properly handle and dispose of a soiled gown, which was observed left on the floor of a resident room near the trash can instead of being placed in the designated soiled linen bin. A CNA and an LVN both acknowledged this as an infection control issue, and the facility's policy requires soiled linens to be collected and stored in a sanitary manner to prevent infection spread.
A resident with a history of mental health conditions and wandering behavior eloped from the facility due to inaccurate risk assessment and inconsistent care planning. Staff failed to provide adequate supervision, and conflicting documentation led to inappropriate interventions. The resident was able to leave the facility unsupervised when staff did not notice his absence, and the facility's policies for assessment and supervision were not properly followed.
A resident with a history of cerebral infarction and atrial fibrillation was denied readmission to the facility after being cleared for discharge from a hospital, even though beds were available. Staff interviews revealed that the resident's bed hold had expired and there was an outstanding share of cost, but these factors should not have prevented her return. The resident experienced significant emotional distress, including sadness and anxiety, as a result of being denied readmission and losing her place of residence.
The facility did not complete required annual Legionella water testing as outlined in its policies, with staff and contracted vendors confirming the missed testing and lack of clarity on requirements. Additionally, a resident on Enhanced Barrier Precautions due to multiple medical conditions had visitors who were not wearing PPE during direct contact, despite staff awareness of the need for enforcement and education. These lapses resulted in compromised infection control practices.
Two residents did not have their care plans updated to address essential needs, including oral hygiene and refusal of care for one resident with severe cognitive and physical impairments, and a change to a puree diet with one-on-one feeding for another resident with metastatic cancer and swallowing difficulties. Staff interviews and observations confirmed that these interventions were not documented or implemented as required by facility policy.
Annual performance evaluations were not completed for two CNAs, as confirmed by personnel file reviews and staff interviews. The facility's assessment tool and staff policies require regular competency validation, but this was not carried out as required.
Two residents experienced medication errors when an LVN administered several medications later than the prescribed time window and another LVN gave the wrong formulation of a cough medication. These actions resulted in a medication error rate of 17.65%, exceeding the acceptable threshold, and were attributed to deviations from physician orders and facility policy.
Nursing staff failed to administer medications as ordered, including giving a pain medication late to a resident and not holding antihypertensive medications for two residents when their blood pressure readings were below physician-ordered parameters. These actions resulted in significant medication errors, as confirmed by staff interviews and medication administration records.
Surveyors found multiple deficiencies in kitchen food safety practices, including expired ham stored in the refrigerator, dirty cooking equipment and food preparation areas, a worn can opener blade, improper hot holding temperatures for TCS foods, and ineffective sanitizer solution used for cleaning food contact surfaces. These issues were confirmed by dietary staff and were not in compliance with facility policy or FDA Food Code.
The QAA and QAPI committees failed to maintain oversight of previously identified systemic issues, including high medication error rates, deficiencies in food and nutrition services, and lapses in the antibiotic stewardship program. These issues, which had been part of the facility's prior plan of correction, were no longer actively managed, resulting in continued deficiencies affecting all residents.
Two residents received antibiotics without proper documentation of indication, duration, or monitoring for adverse reactions. One resident was prescribed Bactrim without an antibiotic time-out or clear reason for use, and another received prophylactic Bactrim without a care plan or monitoring for side effects, contrary to facility policy.
A resident with paralysis and weakness was found in bed without a call light within reach, requiring them to call out loudly for help. Staff confirmed the call light was behind the headboard and not accessible, and acknowledged the importance of keeping it within reach. Facility policy also requires call lights to be accessible to residents.
A resident with multiple mental health diagnoses and moderate cognitive impairment was admitted without an accurate Level 1 PASARR screening. The screening incorrectly indicated no serious mental illness, preventing a required Level 2 evaluation and potentially delaying appropriate mental health services. Facility staff confirmed the screening was not completed correctly, contrary to facility policy.
A resident with severe cognitive impairment and total dependence on staff for activities of daily living was found with poor oral hygiene, including visible food particles and debris on the teeth and lips. Staff interviews and record reviews confirmed that required oral care was neither provided nor documented, and there was no record of care refusals, contrary to facility policy and expectations.
A resident dependent on staff for feeding and with a history of dysphagia was observed being fed in bed while lying on their side with the head of the bed at a low angle, contrary to their care plan and facility policy. Staff interviews confirmed this was not a safe feeding position and could cause swallowing difficulties. The failure to position the resident upright during feeding resulted in a deficiency related to accident prevention and adequate supervision.
A resident with documented allergies to Aspirin and Acetaminophen was prescribed Tylenol by a PMD, but the order was not carried out due to the allergy. Nursing staff notified the PMD but did not follow up for three days to secure an alternative pain medication, contrary to facility policy. This resulted in the resident's pain management needs not being addressed in a timely manner.
An expired fluticasone/salmeterol inhaler prescribed for a resident with asthma was found in a medication cart during an inspection. The inhaler had not been removed after the recommended one-month period post-opening, and the LVN was unaware of the expiration timeframe. This was not in accordance with manufacturer guidelines or facility policy, which require timely removal and destruction of expired medications.
A resident with Parkinson's Disease and dysphagia, requiring a vegetarian and minced and moist diet, was not provided with appropriate menu options or food textures. The kitchen failed to prepare a vegetarian protein alternative, instead serving chopped carrots and, on another occasion, minced shrimp, neither of which met the resident's dietary needs. Staff and dietary supervisors were unaware or did not notice the errors, and the resident's meal tickets clearly indicated the required diet. The food provided did not meet facility policy or the resident's prescribed dietary requirements.
Two residents with significant mobility impairments and pressure ulcers did not have individualized, resident-centered care plans. Instead, their care plans included interventions such as encouraging self-repositioning and education on skin care, which were not feasible due to their dependence on staff for mobility. Staff interviews confirmed the care plans did not reflect the residents' actual needs.
A resident with Parkinson's disease and significant ADL needs experienced a progression of a pressure ulcer from stage 1 to stage 3, but the care plan was not updated to reflect the change or include new interventions. Staff interviews confirmed the care plan should have been revised, in accordance with facility policy.
A resident with Parkinson's disease and existing pressure injuries was not assessed by a treatment nurse for skin and wound status in a timely manner after readmission. Despite facility policy and staff expectations for prompt assessment, the required evaluation was delayed, resulting in a deficiency related to pressure ulcer care and documentation.
Two residents' rights were violated when a facility removed Sit-to-Stand lifts without addressing their concerns, forcing them to use Hoyer lifts. Despite their ability to understand and make decisions, the residents experienced anxiety and discomfort. Staff interviews revealed that the facility did not allow residents to refuse the Hoyer lift, leading to delays in care. The Administrator admitted to failing in communication, acknowledging that residents' concerns were not heard before the decision.
A resident at risk for pressure injuries was left sitting in a wheelchair for four hours due to the facility's inadequate planning during the transition from Sit to Stand (SS) lifts to Hoyer lifts. The resident, with a history of hemiplegia and diabetes, expressed discomfort and anxiety about the change, as the Hoyer lift required more staff and caused delays in care. The facility's lack of anticipation for staffing needs led to increased risk of skin breakdown, contrary to their policy on pressure injury prevention.
A resident at risk for falls, with severe cognitive impairment and requiring assistance, sustained a head injury after getting out of bed unassisted. The facility failed to follow the care plan's intervention for increased monitoring frequency, resulting in the resident being found on the bathroom floor. Staff interviews revealed a lack of awareness and communication about the resident's monitoring needs, and there was no documentation of visual checks.
A resident who underwent knee replacement surgery experienced severe pain due to the facility's failure to provide timely pain management. The resident's prescribed medication was delayed for over two hours because the keys to the medication cart were not properly endorsed during a shift change, and the Registered Nurse Supervisor left with the keys. This resulted in increased pain and anxiety for the resident, who was unable to receive the necessary medication until the keys were returned.
A resident with multiple health conditions, including ESRD, missed two hemodialysis sessions due to transportation errors. Despite the resident's cognitive ability to make decisions, the facility did not hold an IDT meeting to address the missed sessions or involve the resident in care planning, violating their right to participate in their person-centered care plan.
The facility failed to aggressively treat skin breakdown and prevent the progression of contact dermatitis for two residents. Despite multiple evaluations and changes in treatment orders, the residents continued to experience intense itching and scratching. The facility delayed consulting a dermatologist and did not reassess treatment interventions in a timely manner, contributing to the persistence of the residents' conditions.
The facility failed to document a medical condition for a resident's use of mirtazapine and did not monitor the medication's effectiveness or adverse effects. The resident, diagnosed with Alzheimer's, was prescribed mirtazapine for depression without supporting documentation. The facility also did not monitor the resident's behavior or adverse effects, increasing the risk of harm.
A facility failed to maintain a medication error rate below five percent, resulting in an error rate of 26.67%. A resident experienced eight medication errors, including omitted doses and late administration of various medications. The errors were due to medication unavailability and high workload, and the LVN incorrectly marked the MAR. The DON confirmed that the facility's policy was not followed.
A resident did not receive ten doses of Symbicort inhaler as prescribed between 4/1/2024 and 4/10/2024 due to the medication not being available in the facility. The LVN erroneously marked the MAR as if the medication had been administered, and the issue was not reported to the pharmacy, physician, or DON.
Incomplete care planning for hearing, therapy, and fungal toenail treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident admitted with diagnoses including a right humerus fracture, DM, and dementia. The resident’s admission H&P stated the resident had capacity to understand and make decisions, while the MDS described severe cognitive impairment, dependence for hygiene, bathing, dressing, and mobility, and need for supervision with eating. A hearing consult documented moderately severe bilateral hearing loss, with hearing loss significant enough to qualify for hearing aids and greater difficulty discriminating sounds in conversation and hearing higher-pitched voices and sounds. The resident’s PT notes stated the resident had generalized weakness and impaired bilateral ankle ROM causing increased immobility and limiting independence with functional mobility, and that the resident would benefit from PT services including therapeutic exercises, activities, neuromuscular re-education, wheelchair training, and functional activities. OT notes stated the resident had impairments in strength, gross and fine motor coordination, functional activity tolerance, active ROM of the right shoulder, postural stability, and balance, with limitations in self-care and mobility requiring skilled OT services. The comprehensive care plan did not identify the resident’s hearing deficit or need for hearing aids and did not include a focus or problem statement for PT and OT services, with goals and interventions to address hearing, mobility, or ROM needs. A second resident was admitted with ESRD, anemia, heart failure, and DM. The MDS showed moderately impaired cognition and need for assistance with toileting, showering, bed mobility, transfers, dressing, oral hygiene, and eating. During observation, the resident’s toenails were brittle, thick, long, blackish-yellow, and painful, and the resident stated the toenails had not received treatment for the fungal infection, were painful when standing or touched, and caused embarrassment. The podiatry evaluation documented thickened, discolored, brittle, and painful toenails and recommended clotrimazole 1% cream daily, elevating the lower extremities with a foot pillow, applying lotion per facility protocol, providing footwear with a wide toe box, flexible upper, good arch support, cushioned insoles, and avoiding barefoot transportation. The resident’s care plan addressed fungal infection of bilateral toenails but listed only general interventions such as monitoring for adverse effects of clotrimazole, providing treatment as ordered, keeping the skin and toenails clean and dry, and obtaining podiatry consultation, without reflecting the podiatrist’s specific recommendations; the OSR also did not include orders for clotrimazole, a foot pillow, or avoiding barefoot transportation.
Failure to Provide Care-Planned Restorative Nursing Assistance
Penalty
Summary
The facility failed to ensure two sampled residents received Restorative Nursing Assistance (RNA) services as care planned to maintain and/or improve range of motion and mobility. Resident 13 was admitted with diagnoses including a left femur fracture, general weakness, lack of coordination, abnormal posture, and meniscus derangement due to an old tear. The resident’s care plan included Active Range of Motion (AROM) to both upper extremities three times a week as tolerated, and another care plan directed AROM to the right lower extremity, gentle AAROM to the left lower extremity, or use of a bilateral lower extremity omni cycle for 15 minutes three times a week as tolerated. Documentation Survey Reports for April and May 2026 showed RNA services were not administered three times a week during the weeks of 4/19/2026, 4/26/2026, and 5/3/2026, and the RNS confirmed the resident did not receive RNA services three times a week as care planned. Resident 89 was admitted with diagnoses including rhabdomyolysis, contractures in multiple sites, and reduced mobility. The resident’s MDS indicated moderately impaired cognition and need for varying levels of assistance with eating, oral hygiene, toileting hygiene, personal hygiene, and showering. The care plan directed AAROM to both upper extremities five times a week, knee splints to both knees up to 3 hours five times a week as tolerated, and PROM to both lower extremities five times a week as tolerated. Documentation Survey Reports for November 2025 through January 2026 showed RNA services were not administered five times a week during the weeks of 11/9/2025, 11/23/2025, 11/30/2025, 12/21/2025, and 1/4/2026, and the RNS confirmed the resident did not receive RNA services five times a week as care planned. The DON stated RNA services were important to maintain and improve residents’ range of motion, and the facility policy stated maintenance and restorative services were to be provided to maintain or improve residents’ abilities to the highest practicable level.
Inaccurate Bowel and Bladder Documentation
Penalty
Summary
The facility failed to ensure bowel and bladder frequency was documented according to its documentation practices for one resident. During a concurrent interview and record review, the resident’s bowel elimination documentation and MAR for 5/4/2026 through 5/10/2026 were reviewed, and the LVN stated the records showed no bowel movement during that period. The LVN also stated that if a resident has no bowel movement in three days, the facility will implement interventions and administer stool softeners as indicated. During interviews, another LVN stated she remembered the resident having a bowel movement within that same timeframe because she translates for CNAs to communicate with residents. When interviewed with the resident present, the resident stated he had no issues and reported having a bowel movement every day or every two days. The DSD stated accurate documentation was important because it provides a clear indicator of the resident’s daily status, functional abilities, overall health for the day, and any change in condition, and that CNA charting errors could be problematic because charge nurses depend on that information to provide hands-on care. The facility policy on Documentation in Medical Record stated documentation shall be accurate, relevant, and complete, containing sufficient details about the resident’s care and/or response to care.
Failure to Accommodate Resident Seating Preference in Activity Room
Penalty
Summary
The facility failed to assess and address a resident’s seating preferences and to document efforts to accommodate those preferences in the activity room. Resident 43 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, and contractures of the left ankle and left elbow. Her H&P indicated she had the ability to understand and make decisions, and her MDS indicated she was cognitively intact, used a manual wheelchair, and required assistance with several activities of daily living. During observation and interviews, Resident 43 was seated in an oversized wheelchair while doing crossword puzzles and stated there was limited appropriate seating available in the activity room. She explained that only one table was wide enough for her wheelchair and footrests and that she was not always able to secure that preferred seat because of her condition and morning treatments. She later stated that when another resident was seated at that table, she brought the issue to the Activity Director’s attention, but the concern was not addressed and she was told, in front of other residents, that seating was first come first served. Resident 43 stated she felt embarrassed and uncomfortable. The Activity Director stated the resident’s preferred seat was occupied when she arrived and that she was asked to sit at a different table, but no assessment of her seating needs, exploration of alternatives, or documentation of her preferences was completed. A Restorative Nursing Aide stated there was only one of six tables where Resident 43 appeared comfortable and that she could not comfortably sit at the other tables. The DON stated activity staff should assess residents’ needs when preferences are expressed and try to provide alternatives or communication to meet those needs. Facility policies on dignity, accommodation of needs, and activities stated staff must report, document, and act upon resident preferences and make efforts to reasonably accommodate resident needs and preferences.
Inaccurate MDS Did Not Reflect Documented Behavioral Symptoms
Penalty
Summary
The facility failed to provide accurate information in the MDS for Resident 19, who was admitted with diagnoses including psychosis, depressive disorder, and dementia. The resident’s H&P dated 1/9/2026 indicated the resident had the capacity to understand and make decisions, while the MDS dated [DATE] described the resident as severely cognitively impaired and dependent for multiple activities of daily living, including hygiene, bathing, dressing, and mobility. The MDS also indicated the resident did not have physical, verbal, or other behavioral symptoms. The resident’s Order Summary Report directed staff to monitor episodes of psychosis manifested by physical aggression, including grabbing and scratching toward others, and verbal aggression, including screaming and cursing at others, with the number of behaviors recorded every shift. The Monitoring Record for March, April, and May 2026 documented repeated behavioral episodes, including 16 days of physical aggression and 18 days of verbal aggression in March, 19 days of physical aggression and 20 days of verbal aggression in April, and 15 days each of physical and verbal aggression so far in May. During interview and record review on 5/21/2026, the SSA stated the MDS showed no behaviors but should have indicated 4 to 6 days per week, and acknowledged she relied on what she observed during short periods rather than the full day. The SSA stated she should have checked with nursing staff and noted the resident had a care plan for physical and verbal aggression. The MDSN stated she was responsible for ensuring the accuracy of the MDS before submission to CMS and confirmed the resident had behavioral symptoms according to the Monitoring Record and that the MDS should have reflected them. The DON stated the MDS must provide an accurate evaluation of all residents and reflect the care and treatment provided.
Failure to Update Fall Care Plan After Repeated Unwitnessed Falls
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was revised and updated after an unwitnessed second fall on 3/17/2026 that resulted in a cut to the left temple for Resident 7. Resident 7 had been admitted and later readmitted with diagnoses including Parkinson's disease, dementia, syncope, and a history of falls. The H&P dated 1/29/2026 indicated Resident 7 did not have the capacity to understand information and make decisions. The MDS dated 5/5/2026 showed the resident required varying levels of assistance with transfers, toileting hygiene, dressing, bed mobility, oral hygiene, personal hygiene, and eating. The nursing progress note for 3/17/2026 stated Resident 7 was found sitting on the floor mat facing the cabinet with a skin cut on the left temple and was transferred to a GACH via 911. Upon return, Steri-Strips were noted near the left temple. FM 1 reported two unwitnessed falls, one on 1/20/2026 that resulted in a fracture and the second on 3/17/2026 that caused a deep cut above the eyebrow, and stated she was not notified right away. RNS 1 stated both falls were changes in condition and the care plan should have been updated and revised to reflect both incidents. The MDSC reviewed the care plan titled for repeat falls/injury, revised 4/17/2026, which included a goal that Resident 7 would not sustain a major injury from a fall through the review date.
Failure to Provide Nail Care
Penalty
Summary
Provide care and assistance to perform activities of daily living for any resident who is unable. Based on observation, interview, and record review, the facility failed to provide nail care to Resident 89. Resident 89 was admitted with diagnoses including rhabdomyolysis, contractures in multiple sites, and reduced mobility. The MDS dated 3/27/2026 indicated Resident 89 had moderately impaired cognition and required maximal assistance with personal hygiene. The care plan, initiated 8/21/2023, identified a self-care deficit and directed staff to provide assistance with ADLs as needed. During a concurrent observation and interview on 5/18/2026 at 11:27 a.m., Resident 89 was observed in the room with long dirty fingernails and stated a preference to have clean fingernails. During a concurrent observation and interview at 11:30 a.m., CNA 2 observed the long dirty fingernails and stated the nails looked dirty and needed to be cleaned or trimmed. During an interview on 5/21/2026, the DON stated Resident 89's nails should be kept clean and trimmed for a dignified experience and for hygienic reasons. The facility policy titled Nail Care, revised 12/19/2022, stated routine cleaning, inspection, and trimming of nails will be provided as the need arises.
Failure to Implement Podiatry-Recommend Foot Care
Penalty
Summary
The facility failed to implement the podiatrist-recommended treatment for Resident 23’s toenail fungal infection. Resident 23 was admitted with ESRD, anemia, heart failure, and DM, and the MDS indicated moderately impaired cognition with assistance needed for multiple activities of daily living. The OSR showed an order for a podiatry visit and topical treatments, but there was no order for clotrimazole, no order for a foot pillow, and no order to avoid barefoot transportation as recommended by the podiatrist. During observation, Resident 23’s toenails were noted to be brittle, thick, long, and blackish-yellow, and her feet were dry with skin flakes falling off when her socks were removed. Resident 23 stated she had seen the podiatrist a few months earlier but had not received any treatment for the fungal infection on her toenails. She also stated the toenails were painful when she stood up or when they were touched and that their appearance caused her embarrassment. The podiatry evaluation documented thickened, discolored, brittle, and painful toenails and recommended clotrimazole 1% cream daily, elevating the lower extremities with a foot pillow, applying lotion per facility protocol, providing appropriate footwear, and avoiding barefoot transportation. RNS 1 stated these recommendations should have been carried out and care-planned, while the SSD and DON stated staff had not followed through with the podiatrist’s recommendations and were unaware of the current condition of Resident 23’s toenails.
Missing Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to ensure that a performance review for one Certified Nurse Assistant, CNA 9, was completed at least once every 12 months. During a concurrent interview and record review with the Director of Staff Development, CNA 9’s employee file dated from 8/2022 to 5/2026 was reviewed and showed no performance evaluation documented for 2025 and no annual evaluation completed as required. The DSD stated that employee performance evaluations are required upon hire, 90 days after hire, and annually thereafter, and confirmed that CNA 9’s performance evaluation had not been conducted or documented. The DON stated that employee performance evaluations should be conducted at least annually to identify strengths and weaknesses in an employee’s skills and to ensure staff are competent to provide appropriate care to residents. The facility’s policy titled Evaluation Process stated that employees are to receive a formal written evaluation annually, with the manager or supervisor completing the evaluation form and forwarding the original evaluation tools to Human Resources for placement in the personnel file.
Delayed PRN Antiemetic Administration and Inaccurate Controlled Substance Documentation
Penalty
Summary
Failure to provide pharmaceutical services to meet resident needs was identified for two residents. One resident with diagnoses including a neck fracture and protein-calorie malnutrition had intact cognition and required assistance with several activities of daily living. On 4/12/2026 at 9:26 a.m., nursing documentation noted the resident was nauseated and did not have the medication, and at 9:27 a.m. the resident complained of nausea and had vomited in the trash can. An order for ondansetron 4 mg by mouth every 6 hours as needed for nausea and vomiting was entered at 9:39 a.m., but the MAR showed the resident did not receive ondansetron at that time or later that day at 5:12 p.m. The resident received ondansetron at 1:55 a.m. the next day, and it was effective. During interview and record review, the RNS stated the resident had nausea and vomiting in the morning, the ordered medication was unavailable, and the resident again complained of nausea and vomiting later that day without receiving ondansetron. The RNS stated the resident received the medication the next day, about 16 hours after it was ordered, and stated the resident should have received the medication right away. The DON stated that if a resident complained of nausea and was vomiting, the ordered medication should be administered as soon as possible. The facility policy stated medications are to be administered as ordered in a timely manner, and the medication reordering policy stated acquisition of medication should be completed to ensure medications are administered in a timely manner to meet resident needs. A second deficiency involved controlled substance documentation for a resident with ESRD, DM, and CHF who had intact cognition and required supervision to moderate assistance with self-care and mobility. The resident had an order for hydrocodone-acetaminophen 7.5-325 mg, one tablet by mouth every four hours as needed for severe pain. On review of the MAR and controlled drug record at the Station 2 medication cart, the MAR showed the medication was last given at 2:17 a.m., while the CDR sheet showed a different remaining quantity and last dose time. The bubble pack contained 32 tablets, but the CDR sheet indicated 33 tablets remaining with the last dose documented at 8:04 p.m. the prior evening. The LVN stated the nurse who administered the medication forgot to write it on the CDR sheet, and the DON stated the CDR needed to be accurate and that the MAR, CDR sheet, and bubble pack should all match because the medication was a narcotic and discrepancies could allow diversion.
Breakfast Menu Items Missing for Resident With Fortified Diet
Penalty
Summary
The facility failed to provide the fruit cup and health shake listed on one resident’s breakfast menu and diet ticket. Resident 12 was admitted with diagnoses including dementia, gastroesophageal reflux disease, and major depressive disorder. The resident’s MDS dated 4/16/2026 indicated severely impaired cognition and dependence on staff for activities of daily living. The resident’s order summary dated 5/19/2026 indicated a Regular Diet with minced and moist texture, fortified, and a health shake 4 ounces with meals. During a concurrent observation and interview on 5/19/2026 at 7:48 a.m., Resident 12 was observed in the room with CNA 1, and there was no fruit cup or health shake on the tray or bedside table while the CNA was assisting the resident with eating. CNA 1 stated the fruit cup and health shake were not on the tray for breakfast. During a concurrent interview and record review, the Dietary Supervisor confirmed the breakfast menu for that day should have included a minced and moist fruit cup or applesauce. A review of the resident’s diet ticket showed both a fruit cup and health shake were ordered, and CNA 1 stated the resident did not consume them because the items were missing. The DON stated the diet ticket and menu should be followed for nutrition and health reasons. The facility policy titled Menus and Adequate Nutrition stated residents will be offered foods that meet their choices and needs and that menus will be posted and followed.
Infection Control Lapses With Foam Side Rails and Feces-Soiled Laundry Hamper
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed for three sampled residents. Two residents had padded upper side rails wrapped with black foam that were observed in their rooms, and the facility did not ensure those foam-wrapped rails were disinfected appropriately. One resident had diagnoses including dysphagia, Parkinson's disease, and atherosclerotic heart disease, and was documented as severely impaired in cognitive skills for daily decision making and dependent for oral hygiene, toileting hygiene, showering, and personal hygiene. Another resident had diagnoses including contractures, multiple sclerosis, and seizures, and was documented as moderately cognitively impaired and dependent for eating, oral hygiene, toileting hygiene, showering, and personal hygiene. Housekeeping staff stated that deep cleaning of residents' rooms included cleaning the side rails wrapped with porous foam using Sani-Klean weekly and that all equipment, including the foam-wrapped side rails, was cleaned with a disinfectant. During review with the Infection Preventionist, the manufacturer's guidelines for Sani-Klean were reviewed and the IP stated the product was designed for nonporous surfaces. The IP stated using the disinfectant on the porous foam was not appropriate because the foam was porous and could cause the surface not to be cleaned properly and break down the foam. The DON stated the facility should disinfect padded side rails wrapped with porous foam properly to prevent the spread of infection. The facility also failed to keep one resident's personal laundry hamper free from bowel residue. During observation, the hamper in the resident's room had a thin layer of a brown-colored, caked-on substance on the handle, and a CNA stated the substance was feces. The Housekeeping Supervisor reviewed a photograph of the hamper and confirmed it showed visible feces on the resident's personal hamper. The DON stated the presence of feces on objects in a resident's room was unsanitary and posed an infection control risk. The facility policy on routine cleaning and disinfection stated it was the policy to provide a safe, sanitary environment and prevent the development and transmission of infections to the extent possible.
Failure to Report Abuse Allegation and Hip Fracture of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of physical abuse and an injury of unknown origin for a resident with osteogenesis imperfecta who was admitted with extremely fragile bones and intact cognition, and who was dependent on staff for ADLs. Shortly after admission, during a PT evaluation, the resident reported right hip pain and stated that she had been handled roughly by nurses at a prior general acute care hospital (GACH 1); the PT did not report this allegation to supervisory staff, assuming the pain was related to the resident’s underlying condition. Later, nursing documentation showed that the resident’s family member reported the resident had not been handled properly at GACH 1 and that the resident’s hip was not abnormal prior to that hospitalization. Subsequently, nursing assessment identified a prominent protrusion, redness, and warmth of the resident’s right hip, and the physician ordered an X‑ray. Radiology results confirmed an acute displaced fracture of the proximal shaft of the right femur, and the resident was transferred to another hospital for further evaluation and treatment. Despite the resident’s statements that she had been roughly handled by nurses at GACH 1, her denial of any fall or other incident to explain the fracture, and the facility’s policy requiring immediate reporting of all allegations of abuse and injuries of unknown source, the DON acknowledged that CDPH was not notified of either the hip fracture or the abuse allegation. The DON stated that a consultant had advised that the fracture did not need to be reported and that, while the allegation of rough handling should have been reported, it was missed while focusing on the fracture.
Failure to Maintain Door Open for High Fall-Risk Resident, Limiting Staff Visibility
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and observable environment for a resident with a known high fall risk by allowing her room door to remain closed, limiting staff visibility. The resident was admitted with dementia, polyneuropathies, muscle weakness, and difficulty walking, and her MDS showed she was unable to make reasonable decisions, required one-person assistance with ADLs, and was incontinent of bowel and bladder. A fall risk assessment documented a high fall risk score of 16 due to a history of falls, intermittent confusion, poor standing balance, and multiple medications and comorbidities. Her care plan identified risk for falls and injury, with goals for her to remain free from falls and serious injury, and interventions such as anticipating and meeting needs, providing appropriate footwear when ambulating, and maintaining a safe environment. Despite these identified risks, the resident experienced an unwitnessed fall, reported on a Change in Condition Evaluation, in which she sustained a left elbow skin tear. Following this event, IDT notes documented that she was impulsive, had a balance deficit, and attempted to ambulate beyond her capabilities and without assistance. The IDT recommended frequent visual checks, timely assistance as needed, and reminders to nursing staff regarding her safety precautions and plan of care. However, interviews and observations later showed that these recommendations were not consistently supported by maintaining her room door open for visibility. On observation, the resident’s room door was found closed while she was standing barefoot at the foot of her bed, having just come from the bathroom, and she did not know why the door was closed. Her responsible party reported that on multiple visits the door was always closed and expressed concern that staff could not monitor the resident. An LVN confirmed the door was closed and stated staff should have kept it open because the resident was a fall risk and should be visible at all times. A CNA stated he knew the resident was a fall risk from the nursing huddle but did not know how often to check on her, acknowledged that the resident wanted her door closed, and admitted he did not inform licensed staff of this despite her confusion and fall risk. The RN supervisor reported having observed the resident closing her door multiple times and had not yet contacted the responsible party or physician or developed a plan of care to address this safety concern, and acknowledged that staff could not monitor the resident or attend to her needs in a timely manner if her door remained closed. The DON stated the CNA should have informed the LVN about the closed door and that staff should work together to keep care areas accessible, consistent with facility policies on accidents, supervision, and fall prevention that require identification of risks, implementation of interventions, and increased rounds.
Failure to Update Care Plan After Fall for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a high fall-risk resident’s care plan after an unwitnessed fall. The resident, who had dementia, polyneuropathies, muscle weakness, difficulty walking, and was incontinent of bowel and bladder, was admitted with a documented high fall risk score of 16 due to a history of falls, intermittent confusion, poor standing balance, and multiple medications with several predisposing diseases. A care plan dated 1/26/2026 identified the resident as at risk for falls and injury, with interventions such as anticipating and meeting needs, providing appropriate footwear when ambulating, and maintaining a safe environment. On 1/31/2026, a Change in Condition Evaluation documented that the resident reported having fallen earlier that morning and sustaining a left elbow skin tear. Following this fall, an Interdisciplinary Care Conference note dated 2/2/2026 documented that the resident was impulsive, had a balance deficit, and attempted to ambulate beyond her capabilities and without assistance, with recommendations for frequent visual checks, timely assistance, and reminders to nurses regarding safety precautions and the plan of care. However, review of the resident’s care plan showed no revisions or updates to the fall risk interventions after the fall event. A CNA reported knowing only that the resident was a fall risk from shift huddles but was unaware of how often to check on the resident. The RN Supervisor and DON both stated that the resident’s fall risk interventions should have been revised and updated after the fall and once the IDT identified the resident’s safety needs. Facility policies on comprehensive care plans and the fall prevention program required development, implementation, and revision of person-centered care plans and updating care plans as indicated, which was not done in this case.
Failure to Implement Effective Grievance Process for Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective grievance process to ensure resident concerns, specifically about missing personal property, were documented, investigated, and resolved in a timely manner. The facility’s own grievance logs from January to March 2026 showed no grievances related to missing personal property for three sampled residents, despite multiple reports of lost items. The facility’s policy stated that a Social Services designee serves as the Grievance Official, responsible for receiving, tracking, investigating, and resolving grievances, and that staff who receive a grievance must document it and forward it for follow-up. However, staff interviews and record reviews confirmed that these steps were not carried out for the missing property concerns. One resident with Alzheimer’s disease, dementia, major depressive disorder, and impaired cognition, who required assistance with ADLs and was occasionally incontinent, had all personal property reported missing by a family member. The missing items included labeled clothing, a hamper, slippers, blankets, robes, tank tops, and underwear. The family member stated the facility laundered the items and did not return them, that the resident was wearing clothing that did not belong to her, and that the family had to purchase replacement items. The family member reported the issue to multiple staff, including the charge nurse and the Administrator, and stated the Administrator was condescending and lacked empathy. The family member reported that the missing items, valued at approximately $350.45, had not been reimbursed, and the issue remained unresolved. Another resident with orthopedic aftercare following amputation, type 2 DM with hyperglycemia, and hypertensive heart disease, who had moderately impaired cognition and required maximal assistance for bathing and personal hygiene, reported that her purse and wallet had been missing for about three weeks. The missing items contained two checks. She stated she reported the loss to the facility, staff searched but did not locate the items, and she had not been reimbursed. She also stated she did not feel her property was safe and that social services did not assist her with the loss or with canceling the checks. A third resident with DM, bipolar disorder, and schizophrenia, who had intact cognition but was dependent or required maximal assistance for ADLs, reported that personal items such as hair clippers, styluses, and tweezers had been misplaced on multiple occasions over about five months, often after hospital transfers when belongings were packed. He stated he reported the missing items to staff, was told the issue would be reported to a supervisor, but received no follow-up and multiple items remained missing. The Social Services Assistant stated that when items were reported missing, staff should search laundry and rooms, check inventory sheets, and reimburse residents if listed items could not be located, and that missing items should be documented in progress notes and reported to Administration. The SSA acknowledged discussing missing clothing with the family member of the first resident and being aware of missing money and items for the third resident, but did not indicate that grievances had been initiated and stated she was unaware of a missing purse or checks for the second resident. She further acknowledged that grievances should be initiated when residents or families report concerns, including missing property, and that if missing items had been reported, they should have been documented and a grievance filed. The SSA admitted she did not usually handle grievances, was unsure of the grievance process, and that grievances for these missing property concerns had not been documented, resulting in a lack of follow-up and unresolved concerns. The DON stated that when a complaint cannot be resolved immediately, the grievance process should be followed and that missing personal property should have been handled as a grievance because it required investigation and follow-up. The DON acknowledged that no grievances were filed for the missing property complaints from the three residents and that the lack of a grievance process meant the issues were ignored and unresolved. The Administrator stated that when property is lost, Social Services should follow up and, if needed, replace or reimburse the resident, and that the grievance process should be used to ensure timely and efficient handling. The facility’s written grievance policy specified that residents and family members may voice grievances verbally or in writing regarding care, treatment, or other concerns, that staff receiving a grievance must document it and take immediate action as needed, and that the Grievance Official must investigate, follow up, keep the resident informed of progress, and provide a written decision with findings and corrective actions. Despite these requirements, the missing property concerns for the three residents were not entered into the grievance system, not documented as grievances, and not resolved through the required process.
Failure to Provide Timely Incontinence Care, Hygiene, and Dignified Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living, incontinence care, and hygiene for a cognitively impaired resident, resulting in the resident being left undressed from the waist down and lying on urine-soiled linens for several hours. The resident had diagnoses including Alzheimer’s disease, dementia, major depressive disorder, and difficulty walking, and assessments documented that she lacked decision-making capacity, had severely impaired cognition, and required moderate assistance for toileting, bathing, dressing, personal hygiene, sit-to-stand mobility, and toilet transfers. Care plans identified her as being at risk for skin breakdown and urinary tract infection related to occasional bowel and bladder incontinence, with interventions directing staff to check her at least every two to three hours for incontinence, provide perineal care after each episode, and change clothing and linens as needed. On the morning of the survey observation, the resident was found in her room with the door closed and strong air blowing from the vents, stating she was cold. She was observed wearing only a thin blue shirt and was undressed from the waist down, without briefs or underwear. Her bed sheets were soiled with yellowish stains, which were covered by a towel and a chucks pad. Later that day, during a concurrent observation and interview, the resident remained undressed from the waist down on the same soiled linens covered with a towel and chucks pad. The CNA assigned to the resident acknowledged she had not checked on the resident since the start of her shift at 7 a.m. and stated that the towel and chucks pad had been placed by the previous shift. The CNA stated it was not appropriate for the resident to be left lying on soiled linens without a brief and undressed from the waist down, and acknowledged that leaving the resident unattended on wet, soiled linens was unsanitary and could affect the resident’s dignity, comfort, and emotional well-being. The LVN assigned to the resident stated the resident should not have been left undressed from the waist down or lying on soiled, wet linens, and acknowledged that the resident had remained unchecked for approximately five hours, despite the LVN having passed medications at 9 a.m. without checking the resident’s condition. Review of the bathing schedule and ADL bathing flow sheet for that day showed the resident had been scheduled for a shower that morning but did not receive it because the CNA was running behind, and the LVN did not assist or report the delay, despite stating it was her responsibility to do so when nursing assistants were behind. These events occurred despite facility policies requiring prompt cleansing after incontinence, maintenance of personal hygiene and ADLs, treatment with dignity and respect, and prompt attention to soiled linens in order to maintain a clean, sanitary, and comfortable environment.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in which staff failed to keep a resident’s call light accessible and within reach as care planned. The resident had diagnoses including generalized muscle weakness, acquired absence of multiple toes on both feet, UTI, and CKD, and an MDS dated 2/26/2026 showed intact cognition with a need for supervision to touch assistance for ADLs. The resident’s care plan, dated 11/20/2025, documented a risk for falls/injury related to impaired balance and included an intervention to place the call light within reach and encourage its use for assistance as needed. During an observation and interview on 3/9/2026 at 2:45 p.m., the resident’s call light was found on the floor away from the resident, and the DSD acknowledged it was out of reach. At 2:55 p.m., the resident reported he needed the call light under his forearm so he could press it when needing assistance and stated he was looking for the call light every 20 minutes and needed it to get help to empty his urinal. In a 3:47 p.m. interview, the DON stated all residents must have accessible call lights within reach and that staff are instructed to check call lights every hour. At 3:55 p.m., CNA 1 reported that because the resident was large and his body covered the entirety of the bed, he had placed the call light on the bedside table at approximately 11 a.m., thinking it would fall off the bed, and acknowledged he should have placed it within the resident’s reach. Review of the facility’s “Call Light: Accessibility and Timely Response” policy dated 12/19/2022 indicated call lights must be within residents’ reach.
Failure to Obtain Valid POLST and Determine Code Status Delays Life-Sustaining Treatment
Penalty
Summary
The facility failed to obtain a credible Physician Orders for Life-Sustaining Treatment (POLST) for a resident who was capable of signing her own consent. Instead, the POLST was signed by a family member who was only designated as the resident's emergency contact and served as an interpreter, not as the responsible party. The POLST indicated a Do Not Resuscitate (DNR) order and comfort-focused treatment, but the resident's own wishes were not directly documented due to this procedural error. During a medical emergency, staff were unable to determine the resident's code status promptly. Instead of having clear documentation, staff inquired with two family members at the bedside and by phone about whether to initiate CPR. This led to confusion and a delay in starting life-sustaining procedures. Interviews with staff and family confirmed that the family member who signed the POLST was not authorized to make such decisions, and that staff routinely contacted families during emergencies to confirm or change code status, contrary to established policy and the resident's rights. The resident, who had diagnoses including type 2 diabetes, generalized muscle weakness, and anxiety disorder, was noted to have moderately impaired cognition but was still capable of making her own decisions. During the emergency, CPR was not initiated until after family consultation, despite the presence of a DNR order signed by an unauthorized party. Paramedics eventually performed CPR upon arrival, but the resident expired at the facility. Facility policy and state law require that POLST forms reflect the patient's preferences and be followed by healthcare providers.
Failure to Document Indication and Monitor Use of Psychotropic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, psychoactive substance dependence, and Parkinson’s Disease was administered Ativan (Lorazepam), a psychotropic medication, without a clearly documented indication for its use. The resident was cognitively moderately impaired and dependent on all activities of daily living, with impairments in both upper and lower extremities. The care plan specified the use of anti-anxiety medication as needed for anxiety manifested by restlessness and agitation, but the specific manifestations were not consistently documented in the medication administration records or progress notes. Review of the Medication Administration Record showed that Ativan was given on multiple occasions for exhibiting a behavior, but the exact manifestation or behavior warranting the medication was not specified. The order summary for Ativan indicated it was to be given as needed for anxiety manifested by certain behaviors, but the manifestation was not clearly documented. Interviews with nursing staff confirmed that the order was incomplete, missing the required manifestation, and that monitoring of the resident’s behavior and side effects was not consistently documented as required by facility policy. Facility policies required that PRN psychotropic medication orders specify the condition for administration and that adequate indications for use be documented, including ongoing monitoring of mood, behavior, and side effects. The lack of clear documentation regarding the indication for Ativan administration and insufficient monitoring of the resident’s response and side effects led to the deficiency, as the facility failed to ensure that the use of psychotropic medication was appropriate and properly monitored for this resident.
Failure to Properly Handle and Dispose of Soiled Gowns
Penalty
Summary
Facility staff failed to ensure proper handling and disposal of soiled gowns, as evidenced by a soiled gown being observed on the floor of a resident room near the trash can, rather than in the designated soiled linen bins. During observation, a Certified Nursing Assistant (CNA) acknowledged that the gown may have fallen from a plastic bag and confirmed that all staff are expected to place soiled gowns in plastic bags and then into the appropriate barrel. The CNA also stated that housekeepers should be called to clean the area whenever soiled gowns or linens are found on the floor. Additionally, a Licensed Vocational Nurse (LVN) was observed leaving the resident room without picking up the soiled gown, and confirmed that staff are not supposed to leave dirty gowns or linens on the floor due to infection control concerns. The Director of Staff Development (DSD) stated that nurses receive regular in-service training on infection control and that dirty linens or gowns should not be left on the floor, but instead placed in a bag and then in the barrel. Review of the facility’s policy and procedure confirmed that soiled linen should be collected at the point of use, placed in a linen bag or lined receptacle, and not kept in resident rooms or bathrooms.
Failure to Accurately Assess and Supervise Resident at Risk for Elopement
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anxiety, depression, and paranoid schizophrenia eloped from the facility without staff knowledge or supervision. The facility failed to accurately assess the resident's risk for wandering and elopement, as the elopement risk assessment indicated the resident was a low risk, despite documentation of wandering behavior and a history of homelessness, nicotine dependence, and alcohol use. The care plan contained conflicting information regarding the resident's risk factors, and the assessment did not reflect the resident's actual behaviors and history, leading to inappropriate interventions and lack of adequate supervision. On the day of the incident, the resident was last seen on the patio by the receptionist, who did not have a clear line of sight to the front door due to the position of her computer. The receptionist reported that the resident may have exited the facility while she was occupied with other tasks, as a wheelchair was later found near the front door. The LVN on duty last saw the resident in his room, and when the physical therapist went to locate the resident for therapy, he was missing. Staff initiated a search and called a code white for a missing person after realizing the resident was gone. Interviews with facility staff, including the RN and DON, confirmed that the elopement risk assessment and care plan were inaccurate and inconsistent, resulting in a lack of appropriate supervision and interventions. The facility's policies required comprehensive and accurate assessments to inform person-centered care plans and adequate supervision for residents at risk of elopement, but these procedures were not followed, directly contributing to the resident's unsupervised exit from the facility.
Failure to Readmit Resident After Hospitalization Despite Available Beds
Penalty
Summary
The facility failed to ensure that a resident who was transferred to a General Acute Care Hospital (GACH) was readmitted to the facility after being cleared for discharge. The resident, who had diagnoses including cerebral infarction and atrial fibrillation and required moderate assistance with activities of daily living, was transferred to the hospital due to desaturation and altered mental status. Upon stabilization and clearance for discharge from the hospital, the facility denied the resident's readmission, despite having available beds and a policy stating that residents should be permitted to return upon discharge from acute care. Interviews with facility staff, including the Registered Nurse Supervisor, Admission Coordinator, Director of Nursing, and Administrator, confirmed that the resident's bed hold had expired, but there were open beds available and the resident should have been allowed to return. The Admission Coordinator and Administrator both cited the resident's outstanding share of cost as a possible reason for the denial, but acknowledged that inability to pay should not have prevented readmission. The Admission Coordinator admitted to not assisting the resident with her financial concerns or referring her to social services for help. The resident expressed significant emotional distress as a result of being denied readmission, describing feelings of sadness, anxiety, and fear about her future and her belongings left at the facility. The facility's actions resulted in the resident's temporary loss of residence and negative psychosocial outcomes, as evidenced by her vocalizations of depression and loss of trust in the facility staff.
Failure to Implement Infection Control Measures for Water Testing and Visitor PPE
Penalty
Summary
The facility failed to implement required infection control measures in two key areas. First, the facility did not conduct annual Legionella water testing as outlined in its own policies and procedures. Review of the Water Management Program Binder revealed no Legionella testing results for 2024, and the Infection Preventionist Nurse (IPN) was unsure about the annual testing requirement. The contracted testing company confirmed that a scheduled test was canceled by the previous administrator, and the Maintenance Supervisor stated that a risk assessment was performed instead, which he believed could not replace actual Legionella testing. The facility's policies specifically required annual CDC elite Legionella testing, and staff interviews confirmed that this was not completed as required. Second, the facility failed to ensure that visitors of a resident on Enhanced Barrier Precautions (EBP) wore appropriate personal protective equipment (PPE) during their visit. The resident in question had multiple diagnoses, including hemiplegia, hemiparesis, urinary tract infection, dysphagia, diabetes, hypertension, and severe sepsis, and was dependent on staff for daily activities. Observations showed that four visitors were in the resident's room without PPE, engaging in direct contact such as holding hands, hugging, and sitting on the resident's bed. Although the family member was aware of EBP and the location of PPE, staff did not enforce the use of PPE during the visit. Facility policies required staff to educate and remind visitors about EBP and PPE use, but this was not consistently implemented. Staff interviews confirmed the importance of enforcing EBP to prevent the transmission of pathogens, and the Infection Preventionist acknowledged that all staff were responsible for visitor education regarding infection control measures. The failure to follow these protocols resulted in compromised infection control practices within the facility.
Failure to Update and Implement Comprehensive Care Plans for Oral Hygiene and Dietary Changes
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to oral care, hygiene, and dietary needs. For one resident with multiple sclerosis, neuropathy, seizures, and functional quadriplegia, the care plan did not address oral care, hygiene, or the resident's refusal of these activities. Observations revealed food particles and debris in the resident's mouth, and interviews confirmed that oral care was not being provided daily. The resident was dependent on staff for all activities of daily living and had impaired cognitive skills, yet the care plan lacked specific interventions for oral hygiene and refusal of care. Another resident, diagnosed with metastatic breast cancer, seizures, urinary tract infection, and muscle weakness, experienced a change in condition that required a switch from a regular to a puree diet and the need for a one-on-one feeder. Despite these significant changes, the resident's care plan was not updated to reflect the new dietary requirements or the need for individualized feeding assistance. Observations confirmed that the resident was being fed by a certified nursing assistant and required extra time to swallow, but these interventions were not documented in the care plan. Interviews with nursing staff and the Director of Nursing confirmed that care plans should be updated to reflect changes in condition, refusals of care, and specific interventions such as oral hygiene and dietary modifications. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but these requirements were not met for the two residents in question.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two Certified Nurse Assistants (CNAs), as evidenced by a review of their personnel files which showed no evaluations were conducted in the previous year. Interviews with the Director of Staff Development and the Director of Nursing confirmed that evaluations are required upon hire, after 90 days, and annually thereafter, but these were not performed as expected. The facility's own assessment tool also indicated that staff skills and competencies should be validated upon hire and regularly thereafter, in accordance with regulations, but this process was not followed for the two CNAs.
Medication Error Rate Exceeds Acceptable Threshold Due to Late and Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with six medication errors identified out of 34 opportunities, resulting in a 17.65% error rate. The errors affected two residents observed during medication administration. For one resident, a Licensed Vocational Nurse (LVN) administered only part of the scheduled 9:00 AM medications during the initial pass and returned later to give the remaining five medications, including magnesium oxide, aspirin, vitamin C, multivitamins, and gabapentin, after the acceptable administration window had passed. The LVN acknowledged that these medications were late and that this was due to splitting the medication pass, which was not her usual practice. Another error involved a different LVN administering the incorrect formulation of a cough medication to a resident with chronic obstructive pulmonary disease (COPD). The resident was prescribed guaifenesin 100 mg/5 ml oral liquid, but instead received Geri-Tussin DM, which contains a higher dose of guaifenesin and an additional active ingredient, dextromethorphan. The LVN admitted to not verifying the medication formulation against the physician's order and stated that she should have clarified the order with the physician before administration. The facility's policy on medication administration requires that medications be given as ordered by the physician and within 60 minutes of the scheduled time, unless otherwise specified. Both LVNs involved in the incidents acknowledged their errors and the importance of adhering to physician orders and facility policy to ensure safe medication administration.
Significant Medication Errors Due to Late Administration and Failure to Hold Antihypertensives
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in multiple instances. In one case, a nurse administered gabapentin and other medications to a resident later than the physician-ordered time frame. The nurse split the medication pass, resulting in five medications, including gabapentin, being given after the acceptable window. The nurse acknowledged the error, stating that the medications were supposed to be administered by a certain time and that late administration could cause medical complications. In two other cases, the facility did not follow physician-ordered parameters for holding blood pressure medications. For one resident, amlodipine was administered on two occasions when the resident's systolic blood pressure was below the ordered threshold of 110 mmHg. The nurse confirmed that the medication should have been held according to the order and facility policy. Similarly, another resident received both lisinopril and amlodipine when their systolic blood pressure was below the hold parameter. The nurse involved acknowledged that administering these medications under such conditions could further lower blood pressure. The facility's policies required medications to be administered as ordered by the physician, including holding medications when vital signs were outside prescribed parameters. Staff interviews confirmed awareness of these requirements, but the documented medication administration records showed that these protocols were not followed, resulting in significant medication errors for the affected residents.
Deficient Food Storage, Sanitation, and Temperature Control in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. Surveyors observed a large tray of previously cooked ham stored in the walk-in refrigerator past its use-by date. The Dietary Supervisor confirmed that the ham had exceeded its storage date and should have been discarded, acknowledging that old ham can cause illness. Facility policy and the FDA Food Code require proper labeling, dating, and timely use or disposal of refrigerated foods, which was not followed in this instance. Additional observations revealed that the kitchen stove and oven were dirty, with dried food debris, stains, and greasy residue present on the surfaces and knobs. The shelf under the food preparation counter was also found to have food crumbs and debris. The only can opener in the kitchen had a worn, nicked blade, making it difficult to clean and sanitize properly. The Dietary Supervisor and Cook both acknowledged these issues during interviews, and facility sanitation assessment reports had previously noted the need for improvement in these areas. During lunch service, texture-modified fish was held on the steam table at 125°F, below the required hot holding temperature of 135°F. The cook recorded this temperature as acceptable and did not reheat the food, despite facility policy and FDA Food Code requirements. Additionally, food contact surfaces were wiped with a towel stored in a sanitizer solution that was dirty and ineffective, as confirmed by a test strip. The cook admitted the solution was not effective and needed to be changed, contrary to facility policy requiring regular testing and changing of sanitizer solutions.
Failure of QAA/QAPI Committees to Oversee Repeat Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to provide effective oversight of the plan of correction for deficiencies identified during the previous recertification survey. Specifically, the committees did not actively manage ongoing systemic issues related to medication error rates of five percent or more, food and nutrition services, and the antibiotic stewardship program. These areas had been identified as deficient in the prior survey, but were no longer considered high-focus topics by the QAA committee, despite their continued relevance. During interviews and record reviews, the Administrator confirmed that these systemic issues were not currently being addressed by the QAA committee, even though they had been included in the QAPI plan following the previous survey. The facility's policy and procedure for the QAPI plan outlines the need for ongoing data monitoring, performance measurement, and prioritization of problems, but these processes were not being followed for the repeat deficiencies. As a result, all 84 residents were affected by the lack of oversight and continued deficiencies in these critical areas.
Failure to Implement Antibiotic Stewardship Program and Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two residents, resulting in deficiencies related to the monitoring and documentation of antibiotic use. For one resident with a history of acute cystitis, peritoneal abscess, and bacteremia, there was no documented indication for the use of Bactrim, and an antibiotic time-out was not performed after the medication was started. The Infection Preventionist Nurse (IPN) was unable to determine the reason for the Bactrim prescription and found no supporting documentation in the physician or surgeon's notes. Additionally, there was no laboratory testing conducted to justify the initiation of Bactrim, and the medication order lacked an end date, contrary to facility policy and standard practice. For another resident with multiple myeloma and anemia, Bactrim was prescribed for prophylactic use without a care plan or documentation of monitoring for adverse reactions or side effects. The IPN acknowledged that the antibiotic time-out was completed only once, with no subsequent laboratory evaluation or assessment of the resident's status. Nursing progress notes did not include any information about monitoring for side effects or adverse reactions, and the resident's care plan did not address the ongoing use of Bactrim. Facility policy requires that all antibiotic prescriptions specify dose, duration, and indication, and that nursing staff conduct antibiotic time-outs within 48-72 hours of starting therapy. The policy also mandates monitoring for response to antibiotics and documentation of assessments. In both cases, these protocols were not followed, as evidenced by missing documentation, lack of laboratory testing, and absence of care planning and monitoring for adverse effects.
Call Light Not Accessible to Resident with Physical Impairments
Penalty
Summary
The facility failed to ensure that a resident with significant physical impairments had access to a call light within reach. The resident, who was admitted with diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia, and hemiparesis, was observed in bed with the call light placed on the wall behind the headboard, out of reach. The resident confirmed that when the call light was not accessible, he would have to call out loudly for assistance if needed. Staff interviews corroborated the observation, with a CNA and LVN both acknowledging the importance of keeping the call light within reach for residents, especially in case of emergencies or when assistance is needed. A registered nurse further noted that lack of access to the call light could delay care, such as timely assistance with toileting, which could lead to adverse outcomes. Review of facility policy confirmed that staff are required to ensure call lights are accessible to residents while in bed.
Failure to Accurately Complete PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a required Level 1 Preadmission Screening and Resident Review (PASARR) was completed accurately for one resident. The resident was admitted with multiple mental health diagnoses, including depressive disorder, bipolar disorder, anxiety disorder, and mood affective disorder. The resident's history and physical indicated a lack of capacity to understand and make decisions, and the Minimum Data Set (MDS) assessment showed moderate cognitive impairment and significant assistance required for daily activities. The resident was also prescribed high-risk medications such as antipsychotics and antidepressants. Despite these documented mental health conditions, the PASARR Level 1 screening for the resident was marked as negative, indicating no serious mental illness and that a Level 2 screening was not required. The screening form specifically noted the absence of serious diagnosed mental disorders, which contradicted the resident's medical record and diagnoses. This inaccurate completion of the PASARR Level 1 screening prevented the initiation of a Level 2 PASARR evaluation, which is necessary for residents with serious mental illness to determine appropriate care and services. Interviews with facility staff, including Medical Records and the DON, confirmed that the PASARR process is intended to identify residents who require specialized mental health services prior to admission. Staff acknowledged that the Level 1 PASARR was not completed accurately for this resident and that a new screening should have been conducted. The facility's policy requires coordination with the PASARR program to ensure proper screening and referral for residents with mental disorders, but this process was not followed in this case.
Failure to Provide and Document Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including multiple sclerosis, neuropathy, seizures, and functional quadriplegia, was observed to have poor oral hygiene. The resident was found with food particles on the lips and white and orange material on the teeth. The resident was assessed as being severely cognitively impaired and fully dependent on staff for all activities of daily living, including oral care. Despite this, there was no documentation in the nursing progress notes of oral care being provided or refused over a period of several months. Interviews with staff revealed that the facility's protocol required documentation of both the provision and refusal of oral care, with CNAs expected to notify LVNs and the Director of Staff Development if a resident refused care. However, both the LVN and DON confirmed that there was no documentation of oral care or refusals for this resident, indicating that the required care was not provided. The facility's policies also specified that residents unable to perform activities of daily living should receive necessary services to maintain personal and oral hygiene, which was not met in this case.
Resident Not Properly Positioned During Feeding
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dysphagia, gastro-esophageal reflux disease, and muscle weakness, who was dependent on staff for activities of daily living and required assistance with feeding, was not positioned appropriately during mealtime. The resident's care plan specified that the head of the bed should be maintained at 30-45 degrees upright during feeding. However, during an observation, a certified nursing assistant was seen feeding the resident while the resident was lying on their left side with the head of the bed at a low 20-degree angle. The CNA acknowledged that this was not a proper feeding position and that the resident should have been placed in an upright position of at least 60 degrees. Further interviews with nursing staff, including an LVN and the DON, confirmed that feeding a resident in a low side-lying position is not recommended, as it can cause swallowing difficulties and increase the risk of aspiration. The facility's policy and procedure on accidents and supervision also indicated that residents should receive adequate supervision and interventions to reduce hazards and risks. The failure to position the resident upright during feeding was inconsistent with the resident's care plan and facility policy, constituting a deficiency in providing a safe environment and adequate supervision to prevent accidents.
Failure to Follow Up on Pain Management for Resident with Medication Allergies
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was allergic to both Aspirin and Acetaminophen. Upon admission, the resident's records clearly indicated these allergies. Despite this, a Pain Management Doctor ordered Tylenol (Acetaminophen) for pain, which was not administered due to the known allergy. The nurse documented that the PMD was notified about the allergy, but there was no follow-up for three days to obtain an alternative pain medication. Facility policy required staff to follow up with the physician three times within 24 hours and, if no response was received, to contact the resident's primary doctor or the Medical Director. Interviews with staff confirmed that the required follow-up actions were not taken, and the resident's pain management needs were not addressed in a timely manner. The resident's family member reported that the resident experienced stomach pain and was told by the PMD that pain medication would be ordered if needed. The lack of follow-up resulted in the resident potentially experiencing untreated pain, as no alternative pain management was provided during the period in question.
Expired Asthma Inhaler Not Removed from Medication Cart
Penalty
Summary
A deficiency was identified when an expired fluticasone/salmeterol inhaler, prescribed for a resident with asthma, was found in the facility's middle medication cart. The inhaler had been opened and labeled with an open date, but was not removed from the cart after the one-month period recommended by the manufacturer. During an observation and interview, the LVN acknowledged that the inhaler had expired and should have been removed, but was unaware of the specific expiration timeframe after opening. The resident involved had a history of asthma and was admitted to the facility with this diagnosis. The facility's policy required medications to be stored according to manufacturer recommendations and for expired medications to be routinely identified and destroyed. However, the expired inhaler remained accessible in the medication cart, contrary to both manufacturer guidelines and facility policy.
Failure to Provide Appropriate Vegetarian and Texture-Modified Diet
Penalty
Summary
The facility failed to follow standardized recipes and provide appropriate menu options for a resident who required both a vegetarian and minced and moist diet. On the observed lunch service, the cook did not prepare a vegetarian protein alternative for the resident, instead serving steamed carrots as a replacement for fish. The carrots were chopped rather than prepared to the required minced and moist texture, and the resident's meal ticket clearly indicated the need for a vegetarian, minced and moist diet. During the meal, the resident did not consume the chopped carrots, and staff had to mash them further and mix with soup to make them edible. Further observations revealed that the dietary supervisor was unaware of the vegetarian menu requirements for that day and did not notice the improper texture of the carrots served. The following day, the resident was served minced and moist shrimp, which was not appropriate for a vegetarian diet, and the shrimp was noted to be too dry and not minced finely enough. The speech therapist assisting the resident expressed concerns about the food's moisture and texture, and noted the resident's increased risk for aspiration due to posture and swallowing difficulties. The resident's medical history included Parkinson's Disease, dysphagia, and abnormal posture, with documented risks for choking, aspiration, and weight loss. Facility policies required that menus be revised based on resident preferences and that texture-modified diets be prepared as prescribed, with minced and moist foods meeting specific consistency standards. These requirements were not met for the resident in question, as evidenced by the observations and interviews conducted during the survey.
Failure to Develop Resident-Centered Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to develop comprehensive and resident-centered care plans for two residents with pressure ulcers. Both residents had significant impairments: one was admitted with stage 4 pressure ulcers to the sacral region and right hip, and was documented as moderately cognitively impaired and dependent on staff for activities of daily living (ADLs). The other resident, diagnosed with Parkinson's disease, required substantial to maximum assistance with ADLs and had a pressure ulcer on the right buttock and deep tissue injuries to both heels. Despite these conditions, the care plans for both residents only included interventions such as encouraging the residents to frequently shift their weight and educating them or their representatives on skin care, which were not feasible given their dependence on staff for mobility. Interviews with facility staff confirmed that both residents were unable to reposition themselves without assistance, and that the care plans did not reflect the actual care needs of the residents. The treatment nurse acknowledged that the interventions listed were not appropriate for residents who could not reposition themselves, and that staff should have been directed to reposition the residents every two hours. The Director of Nursing also stated that care plans should be individualized and resident-centered, reflecting each resident's specific needs and problems. Review of the facility's policy confirmed that care plans are required to describe resident-specific interventions aligned with their needs and preferences.
Failure to Revise Care Plan After Pressure Ulcer Progression
Penalty
Summary
The facility failed to revise the care plan for a resident after their pressure ulcer progressed from stage 1 to stage 3. The resident, who had Parkinson's disease and required substantial assistance with activities of daily living, was initially documented as having a stage 1 pressure ulcer on the right buttock. Despite the ulcer worsening to stage 3, the care plan interventions remained unchanged, and no updates were made to reflect the new condition or necessary interventions. Interviews with the treatment nurse, Director of Staff Development, and Director of Nursing confirmed that the care plan should have been revised to include updated interventions such as frequent repositioning, a low air loss mattress, and new treatment orders. The facility's policy required the care plan to be reviewed and revised by the interdisciplinary team after significant changes, but this was not done following the progression of the resident's pressure ulcer.
Delayed Pressure Ulcer Assessment After Resident Readmission
Penalty
Summary
A deficiency occurred when a resident, who had been readmitted to the facility with diagnoses including Parkinson's disease and required substantial assistance with activities of daily living, did not receive a timely skin and wound assessment by the treatment nurse following readmission. The resident's records indicated the presence of deep tissue injuries on both heels and a stage one pressure ulcer on the buttocks. According to facility staff interviews, the expectation was that a treatment nurse would complete a skin and wound assessment as soon as possible upon admission or readmission, ideally the same day or the next day, due to the potential for rapid changes in skin condition. Despite these expectations and the facility's policy requiring prompt assessment and documentation of pressure injuries, the treatment nurse did not complete the required assessment until several days after the resident's readmission. This delay in assessment was confirmed through interviews with the treatment nurse, the Director of Staff Development, and the Director of Nursing, all of whom acknowledged the importance of timely wound assessments to ensure accurate documentation and appropriate care. The facility's policy also specified the use of the Braden Scale for risk assessment upon admission or readmission, which was not documented as completed in a timely manner for this resident.
Failure to Uphold Resident Rights in Lift Transition
Penalty
Summary
The facility failed to uphold the rights of two residents when it decided to remove the Sit-to-Stand (SS) lifts without adequately addressing their concerns. Resident 1, who was admitted with conditions such as left hemiplegia, diabetes mellitus, and chronic obesity, was informed of the removal of the SS lift through a notice. Despite having the capacity to understand and make decisions, Resident 1 expressed feelings of depression and anxiety due to the change, as documented in her care plan and social service progress notes. The facility's decision forced her to use a Hoyer lift, which she found uncomfortable and feared falling from, leading to a violation of her rights. Similarly, Resident 2, who had type 2 diabetes with diabetic retinopathy and major depressive disorder, was also affected by the removal of the SS lift. Despite being capable of understanding and making decisions, Resident 2 expressed concerns about the Hoyer lift due to her sensitive skin and existing pressure injuries. She felt that her rights were not being upheld as the facility did not provide an opportunity for residents to voice their concerns before the removal of the SS lift. Interviews with staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed that the facility did not allow residents to refuse the use of the Hoyer lift, which led to delays in care and increased anxiety among residents. The Administrator admitted that the facility failed to ensure that all affected residents were heard before making the decision, acknowledging that better communication could have prevented the anxiety and frustration experienced by the residents.
Failure to Prevent Pressure Ulcer Risk Due to Inadequate Transition Planning
Penalty
Summary
The facility failed to ensure proper care for a resident at risk for pressure injuries, resulting in the resident sitting in a wheelchair for four hours, causing discomfort and increased risk of skin breakdown and infection. The resident, who had a history of left hemiplegia, diabetes mellitus, and chronic obesity, was dependent on staff for various activities and was at risk for developing pressure ulcers. The resident had Moisture-Associated Skin Damage (MASD) in the right abdominal fold and was not repositioned frequently enough after the facility removed the Sit to Stand (SS) lift, which was previously used to assist the resident in transitioning from a seated to standing position. The facility's decision to remove the SS lifts and transition to Hoyer lifts without adequately planning for the increased staffing needs led to the deficiency. The resident expressed concerns about the removal of the SS lift, stating discomfort with the Hoyer lift and anxiety about prolonged sitting in the wheelchair. The facility's notice about the removal of the SS lifts did not offer residents a choice, and the resident was forced to use the Hoyer lift despite objections. The transition required four staff members to assist with the Hoyer lift, which was not anticipated by the facility, resulting in delays in care and the resident sitting in the wheelchair for an extended period. Interviews with the resident, a Certified Nurse Assistant (CNA), and the Director of Nursing (DON) confirmed the deficiency. The CNA and DON acknowledged that the transition to the Hoyer lift was not adequately planned, leading to the resident's prolonged sitting and increased risk of skin breakdown. The facility's policy on pressure injury prevention and management emphasized the commitment to preventing avoidable pressure injuries, but the lack of proper planning and execution in the transition process led to a failure in providing timely and appropriate care for the resident.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate fall prevention measures for a resident assessed at risk for falls, resulting in the resident sustaining a head injury. The resident, who had a history of getting out of bed unassisted, was not monitored with the increased frequency as outlined in their care plan. The care plan, dated 7/1/2024, specified that the frequency of monitoring rounds should be increased to reduce the risk of falls, but this was not adhered to by the nursing staff. The resident, who was admitted with diagnoses including dementia, difficulty walking, and muscle weakness, was found on the bathroom floor with a head injury after attempting to go to the bathroom unassisted. The resident's Minimum Data Set indicated severe cognitive impairment and a need for maximal assistance with toileting and hygiene. Despite these needs, the facility's staff did not follow the care plan's intervention of frequent visual checks every two hours, as evidenced by the resident being last checked at 2 p.m. and found on the floor at 2:45 p.m. Interviews with staff revealed a lack of awareness and communication regarding the specific monitoring needs of the resident. The Director of Nursing and other staff members were not aware of the resident's history of attempting to get out of bed unassisted, and there was no documentation of the monitoring checks. The facility's policy on fall prevention required increased frequency of rounds for at-risk residents, but this was not implemented, leading to the resident's fall and injury.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who had undergone a right total knee replacement and was experiencing severe pain. The resident, who had a history of right knee osteoarthritis and major depressive disorder, reported a pain level of eight out of ten but did not receive the prescribed Oxycodone-Acetaminophen in a timely manner. The resident's care plan included ensuring the availability of pain medication and providing reassurance to manage anxiety, but these interventions were not implemented effectively. The deficiency occurred because the keys to the medication cart were not properly endorsed to a licensed nurse during the shift change. The Registered Nurse Supervisor left the facility with the keys, preventing access to the medication cart and the Emergency Kit. As a result, the resident's pain was not addressed for over two hours, leading to increased pain and anxiety. The resident expressed frustration and anxiety, pacing the hallways and seeking assistance from staff, but was unable to receive the necessary medication until the keys were returned. Interviews with staff revealed that there was a lack of communication and coordination among the nursing staff. The Licensed Vocational Nurse on duty was not able to access the medication cart or the Emergency Kit due to the absence of the keys. The Director of Nursing stated that the staff should have contacted her or the physician to resolve the issue, but this was not done. The facility's policy on pain management emphasized the importance of timely and effective pain management, which was not adhered to in this case.
Failure to Conduct IDT Meeting for Resident's Hemodialysis Refusal
Penalty
Summary
The facility failed to ensure that an Interdisciplinary Team (IDT) Care Conference meeting was initiated for a resident who refused to attend scheduled hemodialysis (HD) sessions. The resident, who had intact cognitive skills and was capable of making decisions, missed HD on two occasions due to transportation issues. The ambulance company mistakenly went to the resident's home instead of the facility, causing delays. Despite these issues, no IDT meeting was held to discuss the resident's refusal of HD or to address the transportation problems. The resident's medical history included conditions such as diabetes mellitus, atrial fibrillation, chronic obstructive pulmonary disease, morbid obesity, end-stage renal disease, anemia, benign prostatic hyperplasia, and dependence on renal dialysis. The facility's policy stated that residents have the right to participate in the development and implementation of their person-centered plan of care. However, the Social Services Director acknowledged that no IDT meeting was conducted to involve the resident in discussing the plan of care or to find solutions to the transportation issues.
Failure to Aggressively Treat Skin Breakdown and Contact Dermatitis
Penalty
Summary
The facility failed to aggressively treat skin breakdown and prevent the progression of contact dermatitis for two residents, Resident 22 and Resident 40. For Resident 22, the facility did not implement the Documentation of Wound Treatments policy and procedure by failing to include the resident's response to the treatment ordered for contact dermatitis. Despite multiple evaluations and changes in treatment orders by the wound specialist, Resident 22 continued to experience intense itching and scratching, indicating that the treatments were not effective. The facility also delayed consulting a dermatologist, which resulted in a diagnosis of Prurigo Nodularis 72 days after the initial diagnosis of contact dermatitis. Resident 40 also experienced a generalized body rash that was not effectively treated. The facility did not reassess treatment interventions in a timely manner, and the resident continued to suffer from intense itching and scratching. Despite being seen by the wound specialist, no new treatment orders were provided, and the resident had not been seen by a dermatologist since January 2024. The facility's failure to consult a dermatologist and reassess treatment interventions contributed to the persistence of the resident's condition. The facility did not inspect all residents in a timely manner for possible contact and spread of skin rashes. The Director of Nurses (DON) acknowledged that several residents had rashes since January 2024, which was unusual. The DON expressed concern about the residents' prolonged discomfort and the potential for skin infections. The facility's failure to follow its policies and procedures for skin assessments and documentation of wound treatments contributed to the residents' ongoing suffering and the potential for further complications.
Failure to Document Medical Condition and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that mirtazapine, a psychotropic medication, was used for a documented medical condition in one resident. The resident, who was admitted with Alzheimer's disease, did not have a diagnosis of depression or major depressive disorder in her clinical records. Despite this, mirtazapine was prescribed for depression manifested by withdrawal from activities of interest, without any supporting documentation or care plans indicating depression as a diagnosis or targeted intervention for the medication's use. Additionally, the facility did not monitor or quantify the target behavior of withdrawal from activities of interest or adverse effects related to the use of mirtazapine. The resident's Medication Administration Record did not show any monitoring for adverse effects or documentation of the resident's behavior per shift. This lack of monitoring and documentation meant that the effectiveness and potential adverse effects of the medication were not being assessed, increasing the risk of harm to the resident. During an interview, the Director of Nursing acknowledged the failure to document a clear medical indication for the use of mirtazapine and the lack of resident-centered care plans. The DON also admitted that the facility did not monitor the resident's behaviors or adverse effects in a meaningful way, which would allow for periodic reassessment of the medication's benefits versus risks. This failure was in direct violation of the facility's policy on the use of psychotropic medications, which requires documented medical conditions and monitoring of the resident's response to the medication.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to ensure that its medication error rate was less than five percent, resulting in an overall medication error rate of 26.67%. This deficiency affected one resident, who experienced eight medication errors out of 30 total opportunities. The errors included omitted doses of Symbicort and Preservision AREDS2, and late administration of aspirin, lisinopril, gabapentin, vitamin C, zinc sulfate, and Eliquis. These errors were observed during a medication pass and confirmed through interviews and record reviews. The resident involved had a history of asthma and macular degeneration and was unable to make his own medical decisions. The errors were primarily due to the unavailability of certain medications in the medication cart and the high workload of the licensed vocational nurse (LVN) responsible for administering the medications. The LVN admitted to marking the Medication Administration Record (MAR) incorrectly, indicating that medications were administered when they were not. The Director of Nursing (DON) confirmed that the facility's policy requires medications to be administered within 60 minutes of the scheduled time and that any missing medications should be reported to the pharmacy, the resident's physician, and the DON. However, the LVN did not follow this protocol, leading to the medication errors. The facility's failure to administer medications as ordered increased the risk of medical complications for the resident.
Failure to Administer Symbicort Inhaler
Penalty
Summary
The facility failed to administer ten doses of Symbicort inhaler to a resident between 4/1/2024 and 4/10/2024, as per the physician's order. The resident, who was admitted with diagnoses including asthma and macular degeneration, was unable to make his own medical decisions. The Medication Administration Record (MAR) indicated that the Symbicort inhaler was scheduled to be given daily at 9:00 AM starting on 4/1/2024. However, the medication was not available in the facility, and the licensed vocational nurse (LVN) responsible for administering it did not follow up with the pharmacy or the physician to resolve the issue or order an alternative medication. During an observation on 4/10/2024, the LVN was seen preparing and administering other medications for the resident but did not administer the Symbicort inhaler. The LVN admitted that the Symbicort inhaler had never been received from the pharmacy due to a cost issue and that she had erroneously marked the MAR as if the medication had been administered. The LVN acknowledged that she marked the MAR in error due to her high workload and did not check which medications were actually administered. She also stated that if a medication is unavailable, it should not be marked as administered in the MAR, and the circumstances should be documented in the nurses' progress notes. The Director of Nursing (DON) confirmed that the LVN should have notified the pharmacy, the resident's physician, and the DON about the missing medication, as it would be treated as a medication error. The DON stated that none of the LVNs had contacted her about the missing medication for the resident. The facility's policy on medication administration requires that medications be administered as ordered by a physician and in accordance with professional standards of practice, and that the MAR should be signed only after the medication has been administered.
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Illustrative
What surveyors actually found near you
We read the 6,766 citations issued within 25 miles in the last 12 months — including the 29 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bellflower
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cerritos Vista Healthcare Center | 0.7 mi | ★★★★★ | 44 | 0 |
| Bellflower Post Acute | 0.7 mi | ★★★★★ | 20 | 0 |
| La Paz Geropsychiatric Center | 1.4 mi | ★★★★★ | 33 | 0 |
| Rose Villa Health Care Center | 1.4 mi | ★★★★★ | 6 | 0 |
| The Springs Post-acute | 1.7 mi | ★★★★★ | 31 | 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 July 2026) and official state health department websites.