Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Serena Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and diagnoses including dysphagia and chronic bronchitis experienced documented changes in condition, including coughing while drinking liquids and pocketing food, as recorded by nursing staff in COC notes. Despite an existing care plan problem identifying risk for impaired nutrition and hydration, the care plan was not revised to address these new swallowing and eating issues. The MDS coordinator and DON acknowledged that the care plan should have been updated in accordance with facility policy, which requires care plans to be revised for changes in condition and new problems.
A resident with severe cognitive impairment, dysphagia, and chronic bronchitis experienced coughing with liquids and pocketing of food, leading a physician to order an SLP evaluation. Nursing documentation did not show that the SLP evaluation addressing these swallowing concerns was completed or that the clinical indication was communicated. The DOR’s rehab screen and the SLP’s account indicated the evaluation was conducted in response to a family request for a diet upgrade, without awareness of the documented coughing and pocketing episodes. This reflected a breakdown in communication between nursing, rehab, and the SLP despite policies and job descriptions requiring appropriate interdisciplinary communication of resident care information and rehabilitative needs.
A cognitively intact resident who required partial/moderate assistance with ADLs reported that a CNA frequently spoke to her in a disrespectful manner during incontinence care, including telling her to do it herself, which caused the resident to cry. While on the phone with the resident during care, a family member overheard staff speaking in a frustrated and aggressive tone and heard the resident respond, "I'm not stupid." Text messages and staff interviews indicated the CNA admitted making the "do it yourself" comment and another CNA reported hearing the CNA direct profanity and hostile remarks toward the resident, as well as complain loudly about hating the job. The DON and an LVN described the CNA as having anger issues and using profanity in an elevated tone that residents could hear, contrary to the facility’s resident rights policy requiring respectful, dignified care.
A cognitively intact resident with hepatic encephalopathy, requiring partial to moderate assistance with ADLs, was allegedly subjected to verbal abuse by a CNA, as reported by the resident’s family member to an LVN after overhearing an aggressive and frustrated tone and the resident crying and saying, “I’m not stupid.” Internal documentation reflected that the resident reported being called “stupid,” and another CNA later reported hearing the alleged CNA use profane and demeaning language toward the resident. Despite these allegations and the facility’s abuse policy requiring reporting of known or suspected abuse, the DON and administrator did not report the incident to state authorities, citing the family member’s inability to hear exact words, the CNA’s denial, and their belief that the incident could not be proven.
Medication administration was not completed as ordered for three residents. One resident receiving narcotic pain medication did not have the required pre- and post-dose RASS assessments documented, another resident with a g-tube was given medication without the ordered pre-flush, and a resident with chronic DVT had a scheduled warfarin dose left blank on the MAR and not addressed. The DON confirmed the ordered flushing and assessment expectations and stated scheduled meds should not be left blank on the MAR.
Uncovered Outdoor Trash Bins: Two large outdoor trash bins near the rear kitchen entrance were observed uncovered on multiple observations, and they contained garbage and food waste. The MD stated outdoor trash bins must remain closed when not in use, the IPN stated trash bins must stay closed to prevent pests and germs, and the DON stated residents with low immune systems could get sick easily if pests enter their area. The facility policy stated waste must be placed in covered bins.
A resident who was cognitively intact and able to feed herself was observed receiving both lunch and breakfast with trays placed on a cluttered bedside table. The resident said she had requested an extra bedside table for meals but had not received one for a month and stated, "I feel like I don't matter." A CNA said the extra table was not provided, and the DON stated staff must ensure residents receive meals with dignity and provide an extra table as needed for a clean eating space.
Failure to Initiate Aspiration Risk Care Plan: A resident with COPD, dysphagia, and dementia had severe cognitive impairment and needed assistance with eating. The RP reported staff fed the resident without fully seating them upright, and the resident later had food and fluid in the lungs during a hospital stay. Record review showed the resident was identified as very high risk for aspiration, with acute bronchitis/aspiration pneumonitis and severe oropharyngeal and esophageal dysphagia, but the facility did not initiate a care plan to address aspiration risk on readmission.
Failure to complete an annual performance evaluation for a CNA was identified during record review and staff interviews. The DSD stated the employee did not receive a performance evaluation in the last 12 months, and the DON confirmed evaluations should be completed every year. The facility P&P stated each employee should receive a performance evaluation at least annually.
A resident with prostate cancer, bone metastases, and palliative care needs received PRN Percocet outside the ordered pain ranges. MAR review showed the medication was given for severe pain when the pain score was 5 and 0, and for moderate pain when the pain score was 2, even though the order summary limited use to moderate pain at 4-6 and severe pain at 7-10. The DON stated the medication should not have been administered for those pain levels.
A facility failed to ensure two resident bedrooms held no more than four residents each. Surveyors observed six residents in each of two rooms, reviewed the administrator-signed waiver showing the rooms were permitted to have no more than four beds per room, and interviewed the ADM, who stated the residents were compatible because they had dementia and could comfort one another.
Resident rooms did not meet required sq. ft. per resident in multiple-bed rooms. Review of the room analysis showed several 2-bed, 3-bed, and 6-bed rooms below the minimum size, and the MD stated he did not know the required sq. ft. per resident or how many residents belong in each room. The ADM stated the facility applies for a room waiver each year because the layout does not meet the sq. ft. requirement, and identified rooms 2 to 9 and 11 to 19 as noncompliant.
Unsigned POLST for Resident With Impaired Decision-Making Capacity: A resident with COPD, heart disease, and moderately impaired cognition had a POLST changed from comfort-focused treatment to selective treatment, but the form lacked the legally recognized decisionmaker’s signature even though it was signed by the MD. When the resident developed rapid respirations, hypoxia, wheezing, and tachycardia, 911 was called; paramedics received an incomplete POLST, could not reach the surrogate, and transferred the resident to a GACH.
A resident with dementia, muscle wasting, and diabetes was found with a skin tear and new skin discoloration after an incident with another resident. Nursing staff notified the physician and updated the care plan but did not initiate a formal change of condition process or conduct a pain assessment as required by facility policy. This resulted in the resident not being properly monitored for changes in condition.
A resident with COPD, ESRD, CHF, and Type II Diabetes Mellitus was neglected by LTC facility staff, leading to their death. Despite being informed of the resident's breathing difficulties, the LVN failed to assess or monitor vital signs, and the RN did not notify the physician or ensure the resident wore a LifeVest. When the resident became unresponsive, proper CPR procedures were not followed, violating facility policies and resulting in the resident's death.
A resident with a Full Code status was found unresponsive, and the facility failed to provide timely CPR. The LVN did not announce a Code Blue or perform CPR, and CNAs stopped chest compressions before paramedics arrived. The facility's failure to follow its CPR policy resulted in a delay in life-saving measures, leading to the resident's death.
The facility did not implement its Water Management Plan, failing to complete a necessary water management assessment to prevent the growth of bacteria, including Legionella. The Infection Prevention Nurse confirmed the assessment was not done, and the facility's policy required following CDC guidance and contracting experts for plan development.
The facility failed to document COVID-19 vaccination status for all employees, including physicians and consultants, potentially placing staff and residents at risk. The Infection Prevention Nurse was unaware of the requirement to obtain this information. The facility's policy required education and offering of vaccinations to all staff and consultants.
The facility failed to meet the required minimum square footage per resident in 17 out of 19 rooms, with rooms having two, three, and six beds not meeting the regulatory standards. Despite a waiver indicating ample space, the survey found rooms like Room 2 with six beds at 470 sq. ft. and Room 3 with six beds at 426 sq. ft. did not meet the minimum requirements. No adverse effects on nursing care or resident comfort were observed during the survey.
A resident at moderate risk for skin injury developed multiple pressure injuries due to the facility's failure to implement care plan interventions and adhere to wound management policies. The resident, with a history of dementia and diabetes, required substantial assistance but was not regularly repositioned, leading to preventable pressure injuries.
A facility failed to provide appropriate dialysis care for a resident with ESRD. The resident missed two dialysis sessions, and the facility did not notify the physician, assess the resident, monitor for complications, or educate the resident on the risks. Additionally, the facility did not complete necessary documentation before a previous dialysis session, impacting continuity of care.
The facility failed to obtain informed consent for psychotropic medications for a resident with decision-making capacity, did not conduct required Gradual Dose Reductions (GDR) for two residents, and inadequately monitored another resident for lithium toxicity. Additionally, there was a delay in addressing a therapeutic duplication of BPH medications for a resident, despite a pharmacist's recommendation.
A resident with breast cancer experienced medication administration errors when an LVN failed to use gloves while handling Anastrozole and did not remove a lidocaine patch as scheduled. This resulted in a medication error rate of 7.69 percent, contrary to the facility's policy and the Director of Nursing's expectations.
The facility failed to store medications securely and maintain the medication refrigerator within the proper temperature range. A resident was observed self-administering and storing medications at their bedside, confirmed by an LVN, while an RN Supervisor stated these should be in the medication cart. Additionally, the medication refrigerator was found to be at 48°F, outside the acceptable range.
The facility failed to follow dietary guidelines during lunch preparation, serving residents on a pureed diet less fish than required and substituting peas for green beans for those on a renal diet. Additionally, fortified diets were not prepared or served to residents needing increased caloric intake. These deficiencies were confirmed through interviews with staff and a review of facility policies.
The facility failed to maintain safe food storage and dishwashing practices. Unlabeled and uncovered frozen food items were found in the freezer, and a dietary aide did not wash hands or change gloves between handling soiled and clean dishes. Additionally, the dishwashing machine was initially using an inadequate concentration of chlorine sanitizer, risking foodborne illness for residents.
A facility failed to follow its antibiotic stewardship program by not monitoring a resident's long-term use of Neomycin for hepatic encephalopathy. The IPN did not review the resident's antibiotic use since readmission, and there was no documentation of clinical indication or monitoring for adverse reactions, contrary to the facility's policy.
The facility was found to be non-compliant with federal regulations by housing six residents in rooms two and three, exceeding the maximum of four residents per room. Although there was space for necessary equipment, the arrangement did not meet regulatory standards. A waiver acknowledged the non-compliance but claimed adequate space for care.
The facility did not provide evidence of the Infection Prevention Nurse completing the required 10 hours of annual continuing education in Infection Prevention and Control. The IPN confirmed she had not completed this education since her initial training in 2023, contrary to the guidelines outlined in the California Department of Public Health's All Facilities Letter 20-84.
A resident with intact cognition and independence was observed self-administering medications without an IDT assessment or physician's order, contrary to facility policy. Interviews with staff confirmed the lack of necessary assessments and orders, highlighting a deficiency in ensuring safe self-administration of medications.
A facility failed to update a resident's medical records to include an advance directive, despite the resident's fluctuating decision-making capacity and existing diagnoses of major depressive disorder, dementia, and hypertension. The Social Service Director admitted that although the resident's family was contacted, the advance directive was not obtained and included in the medical record, contrary to facility policy.
The facility failed to reassess the PASRR for two residents with mental health diagnoses, leading to incorrect screenings that did not reflect their conditions. One resident had major depressive disorder, anxiety disorder, and PTSD, while another had bipolar disorder and was on Lithium Carbonate. The PASRR screenings inaccurately indicated no serious mental illness, risking inadequate care.
A resident with insomnia did not receive their prescribed Restoril medication due to a failure in the facility's pharmaceutical services. Despite a new order for a reduced dosage, the medication was not available, as confirmed by a Registered Nurse Supervisor. The facility's policy requires medications to be available the same day they are ordered, which was not adhered to in this case.
A resident with bipolar disorder had a high lithium level lab result that was not communicated to the physician for five days, contrary to facility policy requiring immediate notification of abnormal results.
A resident with complex medical needs was not provided with a peanut butter and jelly sandwich as ordered by their doctor during snack time. Instead, the resident was given yogurt, despite their requests and dietary orders. Interviews with staff revealed a communication breakdown and failure to adhere to dietary orders, resulting in the resident's dissatisfaction and potential nutritional impact.
A resident on a mechanical soft diet received a quesadilla that was not prepared to meet their dietary needs, as it had dry, crispy edges and was not chopped. The resident, who had missing teeth, was unable to eat the meal and expressed dissatisfaction. The dietary staff acknowledged the meal should have been softer and chopped, and the facility's policies on diet preparation were not followed.
The facility failed to revise a resident's care plan to include necessary fall risk interventions and did not involve the resident's Responsible Party (RP) in the care planning process. Despite the resident's history of falls and cognitive impairments, the care plan was not updated following an unwitnessed fall. This oversight was confirmed by multiple staff members, and the facility's policies for fall risk assessment and care planning were not followed.
A resident with a history of multiple falls and severe cognitive impairment was left unsupervised in the dining room, resulting in an unwitnessed fall. Despite the resident's need for constant supervision, the facility lacked a system to designate staff responsibility for supervision, leading to the incident.
The facility failed to ensure there were enough bath and shower towels for 50 residents, leading to hygiene and infection control issues. Multiple staff members confirmed the shortage, and the DON verified the absence of towels, acknowledging the impact on resident care. The Administrator admitted responsibility and stated that more towels would be ordered.
Failure to Revise Care Plan After Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan following documented changes in condition. The resident had diagnoses including metabolic encephalopathy, dysphagia, and chronic bronchitis, and an MDS dated 1/27/2026 showed severe cognitive impairment with varying levels of assistance required for eating, hygiene, dressing, toileting, and bathing. On 4/5/2026, a change of condition (COC) note documented that the resident was coughing while drinking liquids, and on 4/9/2026, another COC documented that the resident was pocketing food. These events were identified during interviews and record reviews with facility staff, including an LVN who confirmed the COC findings. During a subsequent review with the MDS Coordinator, it was confirmed that the resident’s existing care plan problem of being at risk for impaired nutritional and hydration status was not revised to reflect the new issues of coughing with liquids and pocketing food documented on 4/5/2026 and 4/9/2026. The MDS Coordinator stated that the care plan should have been revised at the time of these COC episodes and acknowledged that failure to revise care plans right away creates a risk for resident decline, not meeting the resident’s needs, or serious injury. The DON also stated that the care plans should have been revised when the COCs were identified. Review of the facility’s Care Planning policy dated 2/9/2024 showed that care plans are to be updated for changes in condition, onset of new problems, and as indicated by clinical assessment, which did not occur in this case.
Failure to Communicate Change in Condition and Indication for SLP Evaluation
Penalty
Summary
The facility failed to meet professional standards of quality by not effectively communicating a resident’s change in condition and the clinical indication for a Speech Language Pathologist (SLP) evaluation. The resident had diagnoses including metabolic encephalopathy, dysphagia, and chronic bronchitis, and an MDS showing severe cognitive impairment and need for varying levels of assistance with ADLs. A change of condition note on 4/5/2026 documented that the resident was coughing while drinking liquids, and another on 4/9/2026 documented that the resident was pocketing food. On 4/9/2026, the physician ordered an SLP evaluation. However, there was no documentation in nursing notes, SLP notes, communication orders, or any change to the order indicating that the SLP evaluation related to these swallowing concerns had been completed or that the indication for the evaluation was communicated. The LVN stated that when an SLP evaluation is ordered, nursing prints the order and provides it to the Director of Rehabilitation Services (DOR), and that completed SLP evaluations are typically reflected in communication orders or modified orders. The DOR’s review of the comprehensive rehab screen dated 4/15/2026 showed the reason for the SLP screening as a family request for a diet upgrade, with no mention that the resident had been coughing with liquids or pocketing food, and the SLP order did not list a reason for referral. The SLP confirmed that they evaluated the resident on 4/15/2026 due to the responsible party’s request for a diet upgrade and that they were not informed of the prior coughing and pocketing episodes. The DON stated it was important for LVNs to communicate the reason for evaluation to the DOR and SLP, and for the SLP to communicate with nursing and review the record for changes of condition, consistent with facility policies and job descriptions requiring appropriate communication of resident care information and clinical needs for rehabilitative services.
Failure to Treat Resident with Respect and Dignity During Care
Penalty
Summary
The deficiency involves staff failing to treat a cognitively intact resident with respect and dignity during the provision of care. The resident, admitted with hepatic encephalopathy but assessed on a recent MDS as having intact cognition and needing partial/moderate assistance with ADLs, reported that a CNA frequently spoke to her in a bad manner while changing her brief, including telling her, "you can do it yourself," which made her cry. On the day of the incident, the resident’s family member was on the phone with the resident during care and overheard staff speaking to the resident in a frustrated and aggressive tone; the family member could not make out the exact words but heard the resident cry and respond, "I'm not stupid." The resident told her family member this was not the first time the CNA had treated her that way and stated to surveyors that such treatment was the CNA’s habit. Other staff interviews and documentation corroborated inappropriate language and behavior by the CNA. A nurse’s note documented that the LVN received a call from the family member reporting overheard inappropriate words from a CNA to the resident, and that the resident was very emotional and felt rushed during care. The DSD’s investigation statement reflected that the administrator reported the resident was crying and alleging the CNA had called her stupid. Text messages to the DSD from the CNA acknowledged telling the resident, "if you don't want me to help, you can do it yourself," and from another CNA reported hearing the CNA say to the resident, "you f*ckin bug so much and sh*t what the f*ck do you want now. I'm so f*ckin tired of your sh*t," and also, "I f*ckin hate this job and I am tired of this sh*t." The DON and LVN both described the CNA as having an attitude problem, using profanity, and displaying anger, with the DON acknowledging that residents could hear the CNA’s elevated, inappropriate language and feel it was directed at them. These actions conflicted with the facility’s Resident Rights policy requiring that each resident be treated with respect and dignity in a manner that promotes or enhances quality of life.
Failure to Report Allegation of Verbal Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving one resident to the California Department of Public Health (CDPH) as required by its abuse reporting policy. The resident, who had hepatic encephalopathy but was assessed as cognitively intact and needing partial to moderate assistance with ADLs, was admitted on a specified date and later involved in an incident on 3/27/2026. On that date, the resident’s family member (FM) called the facility and informed an LVN that a CNA had used inappropriate words in a frustrated and aggressive tone while providing care, and the FM heard the resident crying and saying, “I’m not stupid.” The LVN documented the call and reported the allegation internally to the Director of Staff Development (DSD) and the Director of Nursing (DON). The DSD’s investigation statement documented that the Administrator (ADM) reported the resident was crying and alleging that the CNA had called her “stupid.” A subsequent text message from another CNA to the DSD described hearing the CNA tell the resident, “you f*ckin bug so much and sh*t what the f*ck do you want now. I’m so f*ckin tired of your sh*t.” Despite these allegations and internal reports, the DON and ADM did not report the incident to CDPH. The DON stated the incident was not reported because the FM could not hear the exact words spoken by the CNA and the CNA denied using inappropriate language. The ADM stated the incident was not reported because the resident reported feeling rushed during care, and the ADM believed there was no need to report since they could not prove what happened, the FM could not make out the actual words, and the CNA denied wrongdoing. The FM later stated that during the call on 3/27/2026 she heard an unidentified staff member speaking in a frustrated and aggressive voice while the resident cried and said, “I’m not stupid,” and that the resident told her this was not the first time the CNA had treated her that way. The facility’s written Abuse Prevention and Prohibition Program policy, dated 2/9/2024, states that employees are obligated under the Elder Justice Act and California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse, including allegations of abuse, neglect, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime, but this allegation was not reported to CDPH.
Medication Administration and Documentation Deficiencies
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of three sampled residents. One resident with diagnoses including prostate cancer with bone metastases and palliative care orders received oxycodone-acetaminophen for pain, but the medication administration record did not show completion of the required pre-administration and post-administration RASS assessments for the doses given between 1/17/2026 and 1/24/2026. The resident’s record also showed orders for RASS assessments to be completed before and after narcotic pain medication administration. A second resident with dysphagia and a g-tube was observed on 2/5/2026 with the tube clamped and no feeding running. The LVN administered lasix via the g-tube without flushing the tube before the medication. During the same observation, the LVN flushed potassium chloride through the g-tube. In interview, the LVN stated she would usually flush the tube before giving medication and then flush again afterward to clear residue and keep the tube patent. The DON stated there was an order to flush the g-tube with 30 mL before and after medication administration, and that flushing was needed to ensure patency and that the resident received the full dose. A third resident with chronic DVT of the left lower extremity and atrial fibrillation had orders for warfarin 5 mg on most days and 7.5 mg on Mondays. The resident stated the facility did not give scheduled warfarin for 1 or 2 days. Review of the MAR showed the 1/25/2026 warfarin dose was blank and not documented as administered or addressed. The MDSC stated the blank dose was not indicated as given or addressed, and the DON stated scheduled medications should be given according to the doctor’s order and that there should not be any blanks or unaddressed doses on the MAR.
Uncovered Outdoor Trash Bins
Penalty
Summary
The facility failed to keep waste contained when two large trash bins in the parking lot near the rear kitchen entrance were observed uncovered during an observation on 2/5/2026 at 10:20 a.m. The same two trash bins were again observed uncovered during a follow-up observation on 2/6/2026 at 9:35 a.m. and during a concurrent observation and interview on 2/6/2026 at 10:20 a.m. with the Maintenance Director. The trash bins contained garbage and food waste. During interviews, the Maintenance Director stated outdoor trash bins must remain closed when not in use, the Infection Preventionist Nurse stated trash bins must stay closed all the time to prevent pests and germs, and the Director of Nursing stated residents with low immune systems could get sick easily if pests enter their area. The facility policy dated 2/9/2024 stated waste must be placed in covered bins that are cleaned daily or more frequently if needed.
Failure to Maintain Dignity During Mealtime
Penalty
Summary
The facility failed to promote and maintain dignity for one resident when meal trays were placed on a cluttered bedside table during both lunch and breakfast observations. On 2/4/2026 at 12:52 p.m., the resident was observed seated upright at the edge of the bed with a lunch tray on a cluttered bedside table. On 2/5/2026 at 8:16 a.m. and again at 8:30 a.m. during a concurrent observation with a CNA, the resident was again seated upright at the edge of the bed with a breakfast tray placed on a cluttered bedside table. The CNA stated that the requested extra bedside table was not provided. During interview, the resident stated she had requested an extra bedside table for meals but had not received one for a month and said, "I feel like I don't matter." The resident's record showed admission on 11/28/2025 with diagnoses including DM, UTI, and liver cell carcinoma. The MDS dated 1/16/2026 indicated the resident was cognitively intact, able to feed herself during meals, and dependent on staff for toilet use, transfers, personal hygiene, and bed mobility. The DON stated that staff must ensure residents receive meals with dignity and provide an extra table as needed for a clean eating space. The facility policy titled Privacy and Dignity stated that the facility promotes independence and dignity during mealtime.
Failure to Initiate Aspiration Risk Care Plan
Penalty
Summary
The facility failed to initiate a care plan to address one resident’s risk for aspiration after readmission. The resident had diagnoses including COPD, dysphagia, and dementia, and the MDS dated 10/28/2025 showed severe cognitive impairment, moderate assistance needed for eating and oral hygiene, and maximal assistance needed for toileting, bathing, and lower body dressing. The resident’s Responsible Party reported observing staff feed the resident without seating the resident all the way up multiple times in December 2025, and also stated that when the resident was hospitalized in December 2025, food and fluid were found in the resident’s lungs. During record review, the MDS Coordinator reviewed the hospital follow-up pulmonary and medicine note dated 12/23/2025, which identified acute bronchitis/aspiration pneumonitis and stated the resident was at very high risk for aspiration. The Speech Language Pathologist evaluation and treatment notes dated 12/27/2025 documented severe oropharyngeal dysphagia and esophageal dysphagia. The MDS Coordinator stated a care plan was not initiated on readmission to address aspiration risk, even though care plans are initiated on admission and revised as needed for changes in condition. The DON stated care plans are important to guide care based on diagnoses, medications, and medical problems, and that without a care plan for aspiration risk, staff may not implement appropriate precautions and the resident could receive the wrong diet or choke.
Failure to Complete Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to ensure that CNA 5 received an annual performance evaluation. During a concurrent interview and record review on 2/6/2026 at 1:18 p.m. with the DSD, CNA 5's employee file was reviewed and the DSD stated CNA 2 did not receive performance evaluations in the last twelve months. The DSD stated performance evaluations should be completed every year and filed in the employee file, and that CNA 5's evaluation should have been completed in January 2026. During an interview on 2/6/2026 at 2:34 p.m. with the DON, the DON stated performance evaluations should be completed annually or every twelve months. The facility's P&P titled Performance Evaluations, revised July 2025, indicated a performance evaluation will be completed on each employee at least annually.
Inappropriate Administration of PRN Percocet Outside Ordered Pain Range
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when staff administered oxycodone-acetaminophen (Percocet) outside of the ordered pain parameters. Resident 6 was admitted with diagnoses including malignant neoplasm of the prostate, secondary malignant neoplasm of bone, and encounter for palliative care. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS showed mild cognitive impairment with varying levels of assistance needed for activities of daily living. A review of the MAR showed Percocet was given as needed for severe pain on one occasion when the resident’s pain level was 5 and on another occasion when the pain level was 0. The MAR also showed Percocet ordered for moderate pain was administered when the resident’s pain level was 2. The order summary indicated Percocet was ordered for severe pain at 7-10 and moderate pain at 4-6, and was not ordered for pain levels of 0-3. During interview, the DON stated the medication should not have been given for a pain level of 5 or 0 under the severe pain order, and should not have been given when the resident had no pain.
Excess Residents in Bedroom Rooms
Penalty
Summary
The facility failed to ensure that two resident bedrooms, rooms 2 and 3, accommodated no more than four residents each. During an observation on 2/2/2026 at 12:57 p.m., both rooms were occupied by six residents each. The residents were observed to have no issues moving in and out of the rooms and there was enough space for wheelchairs, beds, and bedside tables. A record review of the waiver signed by the administrator on 3/7/2025 showed that resident rooms were permitted to have no more than four beds per room, and rooms [ROOM NUMBERS] did not meet that requirement under federal regulation. During an interview, the administrator stated that the residents in rooms 2 and 3 were compatible because they had dementia and had been able to comfort one another.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that 17 of 19 resident rooms met the required square footage per resident in multi-bed rooms. During observation, residents in a three-bed room were seen with a wheelchair that was not blocking or hindering other residents, bedside tables, and enough space to go in and out of the room. However, review of the Client Accommodations Analysis dated 2/2/2026 showed multiple rooms that did not meet the minimum square footage requirements, including two 6-bed rooms measuring 470 sq. ft. and 426 sq. ft., several 2-bed rooms measuring 129 to 155 sq. ft., and several 3-bed rooms measuring 187 to 216 sq. ft. The facility identified that the minimum square footage should be 160 sq. ft. for two-bed rooms, 240 sq. ft. for three-bed rooms, and 480 sq. ft. for six-bed rooms. During interview, the MD stated he did not know how many square feet per resident are required in multi-patient rooms or how many residents are supposed to be in one room, and stated he had a room waiver but had not read it. The ADM stated the facility applies for a room waiver every year because the layout does not meet the square footage per resident in multi-patient rooms, and identified rooms 2 to 9 and 11 to 19 as not meeting the required footage. The ADM also stated the room square footage not meeting the requirement had not affected the care provided to residents and would be accommodated as needed. The facility policy titled Resident Rooms and Environment stated that unless a waiver applies, resident rooms must measure at least 80 square feet per resident in multiple resident rooms and 100 square feet in single resident rooms.
Unsigned POLST for Resident With Impaired Decision-Making Capacity
Penalty
Summary
The facility failed to ensure that the legally recognized decisionmaker and physician signed Resident 1’s POLST form. Resident 1 was admitted with diagnoses including COPD and atherosclerotic heart disease, had moderately impaired cognition on the MDS, and the H&P stated the resident did not have capacity to understand and make decisions, with FM 1 identified as the surrogate decision maker. The record showed multiple POLST forms, including one designating DNR status and comfort-focused treatment, and a later POLST designating DNR status and selective treatment; the selective treatment POLST did not contain FM 1’s signature even though it was signed by MD 1. During a change in condition, facility staff called 911 for rapid respirations, hypoxia, bilateral expiratory wheezing, and tachycardia. The 911 Incident Report stated paramedics were given an incomplete and unsigned POLST for selective treatment, could not reach FM 1 to clarify the resident’s wishes, and transferred Resident 1 to a GACH. The DON stated the POLST needed to be signed because it would guide paramedics during a change of condition, and the MRD and SSD stated the POLST should have been signed by the physician and acted upon, but it was not signed as expected.
Failure to Initiate Change of Condition and Pain Assessment for Resident with Skin Injuries
Penalty
Summary
The facility failed to initiate a change of condition (COC) process and conduct a pain assessment for a resident who was found with a skin tear and unknown skin discoloration. The resident, who had diagnoses including dementia, muscle wasting, and Type 2 diabetes, was found with a left forearm skin tear and multiple discolorations on the right upper extremity following an incident involving another resident. Documentation showed that while the physician was notified and the care plan updated, a formal COC was not initiated at the time the new skin discoloration was identified, and a pain assessment was not performed when the skin tear was first observed. Interviews with nursing staff and the Director of Nursing (DON) confirmed that a COC should have been initiated when the skin discoloration was first noted, and a pain assessment should have been completed when the skin tear occurred. The facility's policies require that any change from baseline, such as new skin findings, be documented through a COC process, including ongoing monitoring and pain assessment. The lack of timely COC initiation and pain assessment resulted in the resident not being properly monitored for changes in condition, as required by facility policy.
Neglect Leads to Resident's Death Due to Inadequate Monitoring and Emergency Response
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident's death. The resident, who had a history of COPD, ESRD, CHF, and Type II Diabetes Mellitus, was admitted to the facility and was supposed to have vital signs monitored every shift for 72 hours. However, the licensed nurses did not conduct timely assessments or monitor the resident's vital signs when the resident developed breathing difficulties. Despite being informed by a CNA that the resident was gasping for air, the LVN did not assess the resident or take vital signs, leading to the resident becoming unresponsive and eventually being pronounced dead by paramedics. The RN noted that the resident had an out-of-range oxygen saturation level and was weak, but failed to notify the physician or ensure the resident wore a LifeVest, which was crucial given the resident's risk for sudden cardiac arrest. The RN also did not document any vital signs or assessments after the resident's admission, which was a direct violation of the physician's orders. The LVN, upon being informed of the resident's condition, did not perform an assessment or take any vital signs, and when the resident was found unresponsive, the LVN failed to initiate proper CPR procedures or call a Code Blue. Interviews with staff revealed that the LVN did not follow protocol for emergency situations, such as using the crash cart or providing rescue breaths. The facility's policies on abuse prevention, change of condition notification, and CPR were not adhered to, resulting in the neglect of the resident's care needs. The lack of timely assessments and failure to follow emergency procedures directly contributed to the resident's death.
Removal Plan
- The DON provided RN 1 with a one-to-one in-service regarding responsibilities of a licensed nurse when assessment findings are outside the normal range. The in-service emphasized the importance of monitoring and reassessing the resident to determine the effectiveness of interventions and the resident's response to the interventions.
- LVN 1 was sent home on an administrative leave pending the results of the facility's investigation of the allegation.
- The facility has 48 residents in-house. All residents have the potential to be affected by the same deficient practice.
- The DON reviewed changes in condition to ensure that the residents were assessed timely and appropriately. There were four residents with changes in condition. Licensed nurses assessed the residents timely and appropriately.
- The Administrator and Director of Staff Development (DSD) provided an in-service to facility's employees regarding the facility's policy on Abuse and Neglect Prohibition. The in-service emphasized the following: a. Different types of abuse, including neglect. b. The definition and examples of neglect. c. The responsibility of the staff to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
- The facility staff were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score is 6 out of 6. Staff who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave will be provided the in-service and post-test upon their return to work.
- All new hires will be provided with an in-service and post-test by the Director of Staff Development (DSD) regarding the facility's policy on Abuse and Neglect Prohibition. Staff who don't pass will be asked to attend the in-service and take the post-test again. The in-service will address the following: a) Different types of abuse, including neglect; b) The definition and examples of neglect; c) The responsibility of the staff to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
- The Administrator or designee will provide Abuse and Neglect Prevention in-service to staff quarterly for 1 year and twice a year thereafter.
- The DON and Nurse Consultant provided an in-service to RNs and LVNs regarding managing changes of condition. The in-service emphasized the following points: a) Conducting timely assessments, including vital signs, of a resident who has a change in condition; b) Notifying the physician of changes in condition; c) Monitoring the resident's condition; d) Reassessing the resident to determine the resident's response and the effectiveness of the interventions.
- The licensed nurses were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score is 5 out of 5. Licensed nurses who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave will be provided the in-service and post-test upon their return to work.
- The DON will provide training on managing changes in condition for all newly hired licensed nurses.
- The DON will review changes in condition daily, from Monday through Friday, to ensure that prompt resident assessment was conducted in response to the change in condition. Changes in condition that occur on the weekend will be reviewed the following Monday. Findings will be corrected immediately.
- The Medical Records Director will audit changes in condition daily, from Monday through Friday, to ensure that the medical provider was notified of changes in condition. Changes in condition that occur on the weekend will be audited the following Monday. Findings will be reported to the DON for follow-up.
- The DSD will report the number of new hires for the month and if the abuse in-service training was provided for them to the Quality Assessment and Assurance Committee during the Quality Assurance Performance improvement meeting monthly for three months.
- The DON will report findings and trends from the change in condition review to the QAA Committee during the QAPI meeting monthly for three months.
- The Medical Records Director will report findings and trends from the change in condition audits to the QAA Committee during the QAPI meeting monthly for three months.
Failure to Provide Timely CPR to Full Code Resident
Penalty
Summary
The facility failed to provide timely and appropriate basic life support, including CPR, to a resident with a Full Code status who was found unresponsive. The resident, who had a history of chronic obstructive pulmonary disease, end-stage renal disease, congestive heart failure, and type II diabetes mellitus, was admitted to the facility and later found unresponsive. Despite the resident's Full Code status, indicating a desire for all life-saving measures, the facility staff did not initiate CPR immediately upon discovering the resident's condition. The Licensed Vocational Nurse (LVN) on duty did not announce a Code Blue or provide immediate resuscitation efforts. Instead, the LVN left the resident to call 911, during which time the Certified Nursing Assistants (CNAs) attempted chest compressions without providing rescue breaths or using an Ambu-bag. The facility's policy and procedure for cardiopulmonary resuscitation, which aligns with the American Heart Association guidelines, was not followed, resulting in a delay in life-saving measures. Interviews with staff revealed a lack of coordination and adherence to emergency protocols. The LVN did not perform CPR, and the CNAs stopped chest compressions before the paramedics arrived. The facility's failure to implement its policy and procedure for CPR and Code Blue announcements contributed to the delay in providing necessary life-saving interventions, ultimately resulting in the resident's death.
Removal Plan
- A BLS certified instructor provided BLS training to licensed nurses and CNAs. The training consisted of in person instructions on when to initiate CPR and how to perform the CPR correctly according to the American Heart Association guidelines, and skills demonstration of the proper CPR procedure.
- The DON and the Nurse Consultant conducted a Code Blue drill for nursing staff to simulate a medical emergency. The drill emphasized the staff's responsibility to respond to a medical emergency, the various roles and responsibilities of the staff when responding to a medical emergency, how to operate emergency equipment found in the crash cart, including the Ambu-bag and cardiac board. Nursing staff who were currently on vacation or on leave will be provided the in-service and post-test upon their return to work.
- The DON and Nurse Consultant will conduct a Code Blue drill for nursing staff quarterly for one year and then annually thereafter.
- The DON and Nurse Consultant provided an in-service to Registered Nurses and LVNs regarding managing changes of condition. The in-service emphasized the following points: Conducting timely assessments, including vital signs, of a resident who has a change in condition; Notifying the physician of changes in condition; Monitoring the resident's condition; Reassessing the resident to determine the resident's response and the effectiveness of the interventions; Initiating CPR promptly when the resident is not breathing and/or does not have a pulse. The licensed nurses were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Licensed nurses who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave will be provided the in-service and post-test upon their return to work.
- The DON will review changes in condition daily to ensure that prompt resident assessment was conducted in response to the change in condition. Findings will be corrected immediately.
- The DON will report findings and trends from the change in condition review to the Quality Assessment and Assurance Committee during the Quality Assurance Performance improvement meeting monthly for three months.
- The Medical Records Director will report findings and trends from the change in condition audits to the QAA Committee during the QAPI meeting monthly for three months.
Failure to Implement Water Management Plan
Penalty
Summary
The facility failed to implement its Water Management Plan, which is designed to identify hazardous conditions and minimize the growth and spread of bacteria, including Legionella. During an interview and record review, it was found that there was no documented water management plan, and the Infection Prevention Nurse (IPN) confirmed that the water management assessment had not been completed. The IPN acknowledged the necessity of completing the assessment to prevent microbial growth. Additionally, the facility's policy and procedure on Legionella, implemented in February 2024, indicated that the facility should follow CDC guidance and complete a risk assessment to develop a water management plan. The policy also stated that the facility would contract with experts to assist in this development, considering both internal and external factors that may contribute to Legionella growth.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination status for all employees, including physicians and consultants, which could potentially place staff and residents at risk for serious outcomes such as hospitalization due to COVID-19. During an interview and record review with the Infection Prevention Nurse (IPN), it was revealed that the facility's employee records from 2024 to 2025 did not include the COVID-19 immunization status of physicians and consultants. The IPN admitted to not knowing that she was required to obtain this information. Additionally, the facility's policy and procedure on COVID-19 vaccination, implemented in February 2024, indicated that the facility was responsible for educating and offering COVID-19 vaccinations to all facility staff and consultants, which includes all paid and unpaid individuals working in indoor settings where care is provided to residents or who have resident access for any purpose.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident rooms, affecting 17 out of 19 resident rooms. The deficiency was identified during an observation conducted on January 14, 2025, where rooms with two, three, and six beds were found to have inadequate space per resident. Despite the presence of side tables, chairs, and wheelchairs, the rooms did not meet the regulatory requirements of 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. The facility had previously submitted a room size waiver in January 2024, indicating that there was ample room to accommodate residents and ensure their health and safety. The survey, conducted from January 13 to January 18, 2025, did not observe any adverse effects related to the adequacy of space for nursing care, comfort, and privacy of the residents. The rooms were noted to have sufficient space to accommodate wheelchairs, beds, and other medical equipment, allowing for mobility and locomotion of residents. However, the square footage in several rooms, such as Room 2 with six beds at 470 square feet and Room 3 with six beds at 426 square feet, did not meet the minimum requirements of 480 square feet for six-bed rooms, 160 square feet for two-bed rooms, and 240 square feet for three-bed rooms.
Failure to Prevent Pressure Injuries in a Resident
Penalty
Summary
The facility failed to prevent the development of pressure injuries in a resident who was assessed at moderate risk for skin injury. The resident, who had intact skin upon admission, developed multiple pressure injuries over time, including a Stage II pressure injury on the sacrum, an open area on the buttocks, and another Stage II pressure injury on the coccyx. These injuries were attributed to the facility's failure to implement the resident's care plan intervention to turn and reposition the resident as needed, as well as the failure to adhere to the facility's wound management policy. The resident's medical history included dementia, osteoporosis, type 2 diabetes, and mild protein-calorie malnutrition, which increased their risk for pressure injuries. The Minimum Data Set (MDS) indicated the resident required substantial assistance with daily activities and was dependent on staff for repositioning. Despite these needs, there was no documented evidence that the resident was turned and repositioned regularly, as confirmed by interviews with staff and review of the resident's care records. The facility's policy required minimizing pressure on wounds and notifying the Interdisciplinary Team (IDT) to discuss new interventions for recurring or worsening pressure ulcers. However, the IDT did not meet to discuss new interventions for the resident's recurring pressure ulcers, and there was no documentation of regular repositioning. This lack of adherence to the care plan and facility policies resulted in preventable pressure injuries for the resident.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage renal disease (ESRD) who required hemodialysis. The resident missed scheduled dialysis sessions on two consecutive days due to a rescheduling by the dialysis center and a subsequent refusal to attend the makeup session. The facility did not notify the physician of the missed sessions, assess the resident for potential complications, monitor the resident for symptoms such as shortness of breath or respiratory distress, or educate the resident on the risks associated with missing dialysis. Additionally, the facility did not complete the necessary pre-assessment and communication documentation before sending the resident to dialysis on a previous occasion. The Dialysis Transfer Information form, which is used to communicate the resident's status between the facility and the dialysis center, was left incomplete. This lack of documentation and communication could have impacted the continuity of care for the resident.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for Resident 22, who had the capacity to understand and make decisions. Despite this, consents for Seroquel and Mirtazapine were signed by a family member instead of the resident, and no consent was obtained for Ativan. This oversight was confirmed during an interview with an LVN, who acknowledged that the resident should have signed the consents. The facility also did not conduct Gradual Dose Reductions (GDR) for three residents on psychotropic medications. Resident 41, with intact cognition, had not undergone a GDR for Sertraline and Trazadone, which was overdue. Similarly, Resident 18, with mild cognitive impairment, had not had a GDR for Aripiprazole and Mirtazapine since the last evaluation. The Director of Nursing emphasized the importance of monthly GDR attempts to ensure medication appropriateness and effectiveness. Additionally, the facility failed to monitor Resident 44 for signs of lithium toxicity adequately. The MAR indicated signs of toxicity on specific dates, but the symptoms were not detailed, and there was no clarification with the doctor. Furthermore, Resident 42 experienced a therapeutic duplication of BPH medications, which was not addressed promptly despite a pharmacist's recommendation to discontinue one of the medications. This was confirmed by an RN who acknowledged the delay in discontinuing the medication.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to administer medications appropriately for a resident, resulting in a medication error rate of 7.69 percent. During a medication pass observation, a Licensed Vocational Nurse (LVN) administered Anastrozole to a resident without using gloves, despite the medication label indicating that gloves should be used. Additionally, the resident was found with a lidocaine patch still on their chest, which should have been removed the previous night according to the medication order. The LVN acknowledged the oversight and stated that the patch should have been removed as per the instructions. The resident involved was admitted with a diagnosis of malignant neoplasm of the breasts and required substantial assistance with daily activities. The facility's policy on medication administration, effective since 2017, mandates that medications be administered as prescribed and in accordance with good nursing principles. The Director of Nursing confirmed that medications should be administered as ordered, highlighting the deviation from the facility's established procedures in this instance.
Medication Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure that medications for one resident were stored securely and that the medication refrigerator maintained the appropriate temperature range. During an observation, it was noted that the medication refrigerator had a temperature reading of 48 degrees Fahrenheit, which is outside the acceptable range of 30 to 46 degrees. This discrepancy was confirmed by the Director of Staff Development, who acknowledged the improper temperature. Additionally, a resident was observed self-administering medications, including artificial tears, an inhalation aerosol powder, and nasal solutions, and storing them at their bedside in their luggage. This was confirmed by a Licensed Vocational Nurse, who stated that the medications were in the resident's safekeeping. However, a Registered Nurse Supervisor later indicated that these medications should have been stored in the medication cart for safekeeping, highlighting a failure in proper medication storage practices.
Failure to Follow Dietary Guidelines and Fortified Diets
Penalty
Summary
The facility failed to adhere to the prescribed food production recipes and fortified diet guidelines during lunch preparation and tray line observation. Specifically, the cook used a smaller scoop size to serve pureed fish to residents on a pureed diet, resulting in 10 residents receiving 3 ounces instead of the required 4 ounces per menu. Additionally, three residents on a renal diet were served peas instead of the green beans specified in the menu. These actions were confirmed during an interview with the cook and dietary supervisor, where the cook acknowledged the mistake in scoop size and menu adherence. Furthermore, the facility did not prepare or serve fortified diets to residents who required them. During the tray line observation, the dietary aide failed to communicate the fortified diet orders written on the meal tickets, and the cook did not add the necessary additional food items per the fortified menu. This oversight was confirmed during interviews with the cook, dietary aide, and infection prevention nurse, who noted that fortified diets are crucial for residents experiencing weight loss. The facility's policies, including the Menu Planning Policy and Fortification of Food Policy, were not followed. These policies require that all menu changes be documented and that fortified diets be prepared to increase calorie and protein intake for residents in need. The registered dietitian confirmed the importance of fortified diets in preventing weight loss, highlighting the facility's failure to meet the nutritional needs of its residents as per established guidelines.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. One open bag of frozen pepperoni and a large plastic bag of diced chicken were stored in the freezer without an open date or label, and a bag of frozen chicken thighs was stored uncovered, leading to freezer burn. The Dietary Supervisor (DS) acknowledged that the pepperoni and chicken should have been labeled and dated according to facility policy and the U.S. Food and Drug Administration Food Code. In the dishwashing area, a Dietary Aide (DA1) was observed not washing hands and changing gloves after handling soiled dishes and before touching clean dishes. This action was contrary to the facility's handwashing and glove use policies, which require handwashing and glove changes when moving from a contaminated task to a clean one. The DS confirmed that DA1's actions could lead to contamination of clean dishes, potentially causing foodborne illness among residents. Additionally, the dishwashing machine was found to be using an inadequate concentration of chlorine sanitizer, below the recommended 50-100 parts per million (PPM). The DS initially believed the machine was functioning correctly, but upon testing, the sanitizer level was found to be less than 50 PPM. The DS then changed the sanitizer bucket and retested the solution, which eventually showed an effective level of 50 PPM. However, the initial inadequacy in sanitizer concentration meant that dishes were not properly sanitized, posing a risk of foodborne illness to residents.
Failure to Monitor Antibiotic Use in Resident
Penalty
Summary
The facility failed to implement its protocol for an antibiotic stewardship program by not monitoring the side effects and addressing antibiotic use for a resident. The resident was admitted with a diagnosis including hepatic encephalopathy and was prescribed Neomycin Sulfate Oral Tablet, an antibiotic, for this condition. However, the facility's antibiotic stewardship binder did not include documentation of the resident's Neomycin use from November 2024 to January 2025. The Infection Prevention Nurse (IPN) admitted to not reviewing the resident's Neomycin use since the initial readmission and acknowledged the absence of documented evidence for the clinical indication of long-term Neomycin use. Additionally, there was no documented evidence of monitoring for adverse reactions related to the resident's long-term use of Neomycin. The facility's policy and procedure for the Antibiotic Stewardship Program, dated February 2024, emphasized promoting appropriate antibiotic use and reducing adverse events. Despite this, the facility did not adhere to its own policy, as evidenced by the lack of documentation and monitoring for the resident's antibiotic treatment, which could potentially lead to inappropriate antibiotic use and adverse reactions.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with federal regulations by accommodating more than the allowed number of residents in certain rooms. Specifically, during an observation, it was noted that rooms two and three each housed six residents, exceeding the maximum of four residents per room as stipulated by federal guidelines. Despite the presence of space for wheelchairs, beds, and bedside tables, this arrangement did not meet the regulatory requirements. A waiver submitted by the administrator acknowledged that these rooms did not comply with the four-resident limit but claimed that there was sufficient space to provide care without compromising the residents' health and safety.
Infection Prevention Nurse Lacks Required Continuing Education
Penalty
Summary
The facility failed to provide documented evidence of 10 hours of continued education in the field of Infection Prevention and Control (IPC) for the Infection Prevention Nurse (IPN). During an interview, the IPN stated she did not complete the required annual 10 hours of continuing education in IPC after her initial training in 2023. A review of the California Department of Public Health All Facilities Letter (AFL) 20-84 indicated that ongoing education in IPC is necessary for infection preventionists to remain informed about new information, trends, and best practices. The AFL specifies that the IP should complete 10 hours of continuing education in IPC annually, and facilities should support IP staff in staying updated through recognized infection prevention and control associations.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to assess a resident's capability to self-administer medications, which is a requirement according to the facility's policy. The resident, who was admitted with diagnoses including allergic rhinitis and asthma, was observed self-administering various medications such as artificial tears, Fluticasone Salmeterol inhalation, Ipratropium Bromide nasal solution, and sodium chloride nasal solution. Despite the resident's intact cognition and independence in self-administering these medications, there was no documented assessment by the IDT or a physician's order permitting the resident to self-administer medications. During interviews, both a Licensed Vocational Nurse and a Registered Nurse Supervisor confirmed that the resident had been self-administering medications without the necessary assessments and orders. The Director of Nursing reiterated that self-administration of medications is only allowed if a physician orders it and the IDT assesses the resident's capability. The facility's policy requires that the results of such assessments be recorded in the resident's medical record, which was not done in this case.
Failure to Document Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical records were updated to reflect the presence of an advance directive, which is a written statement of a person's wishes regarding medical treatment. This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including major depressive disorder, dementia, and hypertension. The resident's history and physical indicated fluctuating capacity to understand and make decisions, while the Minimum Data Set showed intact cognitive skills and varying levels of assistance required for activities of daily living. The Social Service Director (SSD) acknowledged that although the resident's family was contacted about the advance directive upon admission, a copy was not obtained and included in the resident's medical record. The facility's policy requires that a copy of the advance directive be obtained and included in the medical record upon admission. The absence of this documentation had the potential to cause conflict with the resident's healthcare wishes.
Failure to Reassess PASRR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) assessments for two residents, Resident 39 and Resident 44, were reassessed to determine the facility's ability to meet their special needs. Resident 39 was admitted with diagnoses including major depressive disorder, anxiety disorder, and PTSD. Despite these diagnoses, the PASRR Level I screening incorrectly indicated that Resident 39 did not have a serious mental illness. The Minimum Data Set Coordinator (MDSC) acknowledged this discrepancy during an interview, noting that the PASRR is crucial for identifying residents who may require follow-up care. Resident 44 was admitted with diagnoses including bipolar disorder, alcohol abuse, and adult failure to thrive. The PASRR Level I screening for Resident 44 also failed to indicate a serious mental illness, despite the resident's diagnosis of bipolar disorder and treatment with Lithium Carbonate. The MDSC confirmed that the PASRR was not filled out correctly, which could lead to the resident not receiving the necessary care. The facility's policy and procedure for PASRR, dated February 9, 2024, states that all facility applicants should be screened for mental illness and/or intellectual disability. However, the failure to reassess the PASRR for these residents placed them at risk of not receiving the necessary care and services they need, as the screenings did not accurately reflect their mental health conditions.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medication, Restoril, was available as prescribed. The resident, who was admitted with a diagnosis of insomnia, had their Restoril dosage reduced from 30 mg to 15 mg on January 11, 2025. However, during a resident council meeting on January 14, 2025, the resident reported that they had been waiting for their medication for a couple of days. An observation and interview with a Registered Nurse Supervisor confirmed that the medication was not available in the medication cart, despite a new order for the reduced dosage being present in the system. The Director of Nursing acknowledged that ordered medications should be available for residents. The facility's policy and procedure, effective since April 2008, mandates that pharmaceutical services should be reliable and available 24/7, with medication orders being fulfilled on the same day they are placed. This deficiency in pharmaceutical services had the potential to negatively impact the resident's health due to the lack of sleep medication.
Delayed Notification of Abnormal Lab Result
Penalty
Summary
The facility failed to inform the physician about an abnormal laboratory result in a timely manner for a resident, which placed the resident at risk for delayed treatment. The resident, who was admitted with diagnoses including bipolar disorder, alcohol abuse, and adult failure to thrive, had a lithium level blood test ordered and completed. The lab results, indicating a high lithium level, were collected and received on the same day, but the physician was not notified until five days later. Interviews with nursing staff revealed that the facility's policy requires abnormal lab results to be reported to the physician immediately. However, the delay in notifying the physician about the high lithium level was not in accordance with this policy. The facility's policies on laboratory services and the responsibilities of licensed vocational nurses emphasize the importance of timely communication of abnormal test results to the ordering practitioner.
Failure to Provide Ordered Snack to Resident
Penalty
Summary
The facility failed to provide a resident with a peanut butter and jelly sandwich as requested during snack time, which was part of the resident's dietary orders. The resident, who has a history of malignant neoplasm, anemia, and congestive heart failure, was dependent on staff for assistance with eating. Despite the resident's request and the doctor's order for a specific snack, the resident was repeatedly given yogurt instead. Interviews with staff revealed a breakdown in communication and adherence to dietary orders. The Certified Nurse Assistant and Dietary Aide both provided the resident with yogurt, as it was listed on the nourishment list, but failed to provide the peanut butter and jelly sandwich as ordered. The Dietary Supervisor admitted to missing the order, and the Licensed Vocational Nurse acknowledged the oversight in checking the diet against medical records. The Director of Nursing confirmed that there was a communication lapse between the speech therapist, dietary staff, and nursing staff, resulting in the resident not receiving the ordered snack. The facility's policies on food preferences and nourishment were not followed, leading to the resident's dissatisfaction and potential impact on their nutritional intake.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a meal that met the dietary needs of a resident on a mechanical soft diet. The resident, who had been admitted with conditions including chronic obstructive pulmonary disease and dysphagia, received a quesadilla that was not prepared according to their dietary requirements. The quesadilla had dry, crispy edges and was not chopped, making it difficult for the resident, who had missing teeth, to consume. The resident expressed dissatisfaction with the meal, stating it was overcooked and dry, and requested not to receive quesadillas in the future. The dietary staff, including the cook and the registered dietitian, acknowledged that the quesadilla should have been prepared softer and chopped to meet the mechanical soft diet requirements. The cook did not use a standardized recipe, which contributed to the inappropriate texture of the meal. Additionally, the quesadilla was not fortified as required by the resident's diet order, which called for extra caloric content. The facility's policies on mechanical soft diets and menu planning were not followed, leading to the resident's meal dissatisfaction and potential health risks.
Failure to Revise Care Plan and Include Responsible Party
Penalty
Summary
The facility failed to ensure that Resident 2's care plan was revised to include interventions to reduce the resident's fall risk, such as direct line of sight supervision while the resident was awake. Despite the resident's history of falls and cognitive impairments, the care plan was not updated following an unwitnessed fall on 5/14/2024. The IDT meeting held on 5/15/2024 discussed necessary interventions, but these were not incorporated into the care plan. Additionally, the resident's Responsible Party (RP) was not included in the care planning process during the IDT meeting, violating the resident's and RP's rights to be involved in the care planning process. Resident 2 was admitted with diagnoses including overactive bladder and major depressive disorder with severe psychotic symptoms. The Minimum Data Set (MDS) indicated that Resident 2 had severely impaired cognitive skills and required supervision for various activities. Despite these needs, the care plan did not reflect the necessary interventions discussed in the IDT meeting, such as direct line of sight supervision. This oversight was confirmed by the Infection Preventionist Nurse (IPN), Director of Rehabilitation (DOR), and Director of Nursing (DON), who all acknowledged that the care plan was not updated appropriately. The facility's policies and procedures for fall risk assessment, response to falls, and care planning were not followed. The policies indicated that the IDT team should review and modify the care plan as needed and that the resident and their family should be involved in the care planning process. The failure to revise the care plan and include the RP in the IDT meeting led to the resident's unwitnessed fall and could result in further falls and injuries. The DON confirmed that the facility did not notify the RP of the IDT meeting, violating the resident's rights.
Failure to Supervise Resident with History of Falls
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of multiple falls, resulting in an unwitnessed fall. Resident 2, who was admitted with diagnoses including overactive bladder and major depressive disorder with severe psychotic symptoms, had severely impaired cognitive skills and required supervision for various activities, including transfers and ambulation. Despite these needs, Resident 2 was left unsupervised in the dining room by CNA 1, leading to an unwitnessed fall on 5/14/2024. Resident 2's history of falls was well-documented, with multiple incidents occurring between 6/30/2023 and 5/30/2024. The Morse Fall Scale Reports indicated that Resident 2 had falls on 7/21/2023, 9/2023, 5/4/2023, and 5/14/2023. On 5/14/2024, an unidentified resident called for help, stating that Resident 2 was on the floor. The SBAR communication form note confirmed that Resident 2 was found on the floor in a sitting position near her wheelchair, having sustained an unwitnessed fall. Interviews with various staff members, including the Infection Preventionist Nurse, Director of Rehabilitation, Registered Nurse 1, and CNA 1, revealed that Resident 2 required constant supervision due to poor safety awareness and frequent attempts to stand up unattended. However, the facility did not have a system in place to designate which staff member was responsible for supervising Resident 2. This lack of a system led to Resident 2 being left unattended in the dining room, resulting in the unwitnessed fall. The facility's policy on fall risk assessment indicated that the environment should be free of accident hazards and that residents should receive adequate supervision to prevent accidents, which was not adhered to in this case.
Towel Shortage in Facility
Penalty
Summary
The facility failed to ensure there were enough bath and shower towels for 50 out of 50 sampled residents. This deficiency was identified through multiple observations, interviews, and record reviews. Resident 2 reported having to wait until the next day to receive towels for bathing, indicating a towel shortage. Central Supply confirmed the lack of towels and mentioned that it sometimes takes more than a day to replenish the supply. The laundry assistant noted that clean towels are delivered by an external company twice a week, but there were no towels available in the facility at the time of observation. Certified Nursing Assistants (CNAs) also confirmed the shortage, stating they had to use personal cleansing wipes or residents' gowns and sheets for hygiene purposes due to the lack of towels. The Director of Nursing (DON) verified the absence of towels on the linen carts and in the linen room, acknowledging that this issue prevents proper resident care and poses an infection risk. The Administrator admitted responsibility for ensuring an adequate supply of towels and stated that more would be ordered moving forward. The facility's policies and procedures for infection prevention and control, as well as laundry services, were reviewed and found to be inadequate in maintaining sufficient quantities of clean linen to meet residents' needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,713 citations issued within 25 miles in the last 12 months — including the 21 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Long Beach Post Acute | 0.6 mi | ★★★★★ | 18 | 0 |
| Colonial Care Center | 0.7 mi | ★★★★★ | 35 | 0 |
| Courtyard Care Center | 1.1 mi | ★★★★★ | 28 | 0 |
| Edgewater Skilled Nursing Center | 1.2 mi | ★★★★★ | 21 | 0 |
| Broadway By The Sea | 1.4 mi | ★★★★★ | 26 | 0 |
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