Below 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 Virgil Rehabilitation & Skilled Nursing Center during CMS and state inspections, most recent first.
The facility failed to properly store, date, and remove medications and supplements from a medication cart and medication room refrigerator, including unopened latanoprost vials not refrigerated or dated, an opened Humulin R vial without an open date, expired vitamin C, expired glucose gel, expired Boost Breeze, and expired discontinued insulin aspart pens. The facility also failed to include hazardous drug handling instructions for bicalutamide for a resident with a G-tube, and an LVN was observed crushing the medication without gloves while the pharmacy label and eMAR did not identify it as hazardous.
Unsafe food storage and prep practices were observed in the kitchen and on med carts. Expired tomato sauce was found in the walk-in refrigerator, raw ground beef was thawing with no date, and a can opener blade was worn and had sticky brown residue. Apple sauce used for crushed meds was also left at room temperature on two med carts without ice for longer than 4 hours, and the DS and DON confirmed the conditions.
Overfilled dumpster bins left uncovered. Two trash bins in the main dumpster area were observed overfilled with the lids open and pushed against a wall so they could not be closed. The DS, HS, CM, and MS stated the lids should have been kept closed to prevent pests, and the facility policy and FDA Food Code required outside refuse receptacles to be covered and inaccessible to insects and rodents.
Failure to Obtain Informed Consent for Diazepam: A resident with seizures, muscle spasms, hepatic encephalopathy, and sequelae of cerebral infarction was given diazepam for spasms without documented informed consent. Record review found no signed consent, no H&P or physician progress notes in the chart, and staff confirmed the prescriber and the resident’s representative had not signed the form. The family member stated no one discussed the medication’s informed consent, and the DON said the facility did not follow its Resident Rights policy.
The facility failed to reasonably accommodate the needs of three residents by not providing a Korean communication board for a resident whose preferred language was Korean, not providing a communication board for a resident with hearing-related communication needs, and not providing an appropriate call light for a resident with severe vision, cognitive, and hand-function limitations. Observations and staff interviews showed the residents lacked the supports identified in their care plans, and staff stated the missing communication tools and traditional call light were not appropriate for the residents’ needs.
A resident’s medical information was left visible on an unattended medication cart computer screen facing a public hallway. The screen displayed the resident’s name, DOB, physician, room number, code status, allergies, and orders, while an LVN was working nearby at the nurses’ station and stated the screen should not have been open for public view. The DON stated resident information should always be kept private, and facility policies required protected health information to be secured and covered.
Informed Consent Not Properly Obtained for Psychotropic Medication: A resident with dementia, schizophrenia, and severe cognitive impairment was prescribed Risperidone via g-tube for schizoaffective disorder with auditory hallucinations, but the facility documented informed consent from the resident even though staff later acknowledged she lacked capacity to make health care decisions. RN, LVN, MDSC, and DON interviews confirmed the resident was confused and should not have been the consent source, and the chart did not show that consent was obtained through a family member, friend, aging department, or IDT process.
Failure to Report Injury of Unknown Origin: A resident with significant cognitive and physical impairments developed left ankle swelling, pain, and discoloration, and an x-ray showed an acute fracture of the distal fibula. Staff and leadership stated they did not know how the injury occurred, found no fall or rough handling, and did not report the injury of unknown origin to the SSA or ombudsman within the required timeframe.
Unsafe Handling of Hazardous Medications During G-tube Administration: An LVN prepared and crushed bicalutamide and finasteride for G-tube administration without following hazardous drug handling procedures, including handling bicalutamide without gloves and crushing both medications in plastic bags. The resident had BPH and a G-tube, and the LVN later stated she had researched both drugs as hazardous. The DON stated the facility did not have the necessary chemo gloves or gowns, and the facility policy required chemo-rated gloves and no crushing of hazardous tablets unless pharmacy-approved containment was used.
A resident with hemiplegia, aphasia, dysphagia, and contractures had a decline in right knee ROM identified on the JMA, and a right knee extension splint was ordered and used without a PT eval. The DOR stated a PT eval was needed to establish baseline ROM, set splint wear tolerance goals, monitor skin, and train the RNA on splint application. The resident was observed with the right leg bent at the knee while the RNA performed PROM and applied the splint.
Uncapped enteral feeding tube exposed to air. A resident with a GT and diagnoses including dysphagia, GI bleeding, and malnutrition had an enteral feeding tube connected to the feeding bag that was observed uncapped and exposed to the air. An LVN, the IP, and the DON acknowledged the exposure and stated it could be a source of infection; the DON also stated the facility did not follow its enteral feeding policy.
A resident with GERD had a famotidine order that lacked a frequency, and the MAR showed the medication was not administered during the review period. In a separate case, a resident with a right BKA, diabetic neuropathy, and CKD had PRN lidocaine 4% patch orders for stump and back pain, but the facility did not have the patches in stock and no administrations were documented. Staff interviews confirmed the missing order detail and the lack of available medication.
Failure to ensure staff wore required face masks during respiratory virus season. An IPN stated staff had to wear masks inside the facility, especially in resident rooms, to protect residents from respiratory viruses. However, CNA 1 was observed in a resident room without a face mask, including during a second observation and interview, despite stating staff were supposed to wear masks while inside the facility. The DON also confirmed the facility required face masks during flu season, and the facility’s Respiratory Virus Prevention and Control Plan and in-service materials addressed source control masking during increased community transmission.
Excess Residents in Multiple Shared Rooms: The facility failed to ensure four resident rooms met the requirement of no more than 4 beds per room. A Room Variance Waiver Request stated the rooms had enough space for care, dignity, privacy, and residents’ special needs, and observations found space for therapy, resident activity, and nursing services. Staff and a resident stated there was enough room to provide services, and the facility policy required no more than 4 residents per room unless a waiver was requested.
Two residents with dementia, weakness, and impaired mobility who required maximal assistance for transfers and locomotion were observed seated in wheelchairs without footrests, despite one having PT-indicated need for footrests and the other having orders for a wheelchair alarm and a floor mat. Staff interviews confirmed that the wheelchair for one resident lacked footrests and an alarm and that no floor mat was present, while the activity assistant reported not being trained in wheelchair transfers or aware of why footrests were missing. Nursing and therapy staff acknowledged that residents with weakness or fall risk should have footrests and that ordered alarms and floor mats must be implemented, yet these interventions were not in place as required by the facility’s fall management policy.
Delayed Reporting of Resident Elopement: A resident with end stage HF, dilated cardiomyopathy, CKD, acute pulmonary edema, cocaine abuse, and hospice status left on pass and did not return. Although the care plan identified elopement risk, staff made repeated unsuccessful attempts to reach him and did not notify CDPH, the Ombudsman, and law enforcement until the next day, despite the facility’s elopement policy requiring prompt reporting when a resident could not be located.
Missing care plan for out on pass order: A resident with end stage HF, dilated cardiomyopathy, CKD stage 2, acute pulmonary edema, cocaine abuse, and hospice status had an order to go out on pass, but staff verified there was no individualized care plan for the pass order and no IDT assessment could be located. The resident was cognitively able to understand and make decisions, but required assistance with multiple ADLs, and an RN stated the facility could not assess the resident’s safety without following the out on pass policy.
A resident with end stage heart failure, hospice care, and a known elopement risk was allowed out on pass without an IDT review with hospice, without a clear physician order on supervision or accompaniment, and without a specified return time. Staff later could not locate the resident after he failed to return, and interviews showed the facility did not follow its out on pass and elopement policies.
A resident with end stage heart failure, dilated cardiomyopathy, CKD, and hospice status was allowed out on pass without the required IDT assessment, clear physician direction, or an agreed return time. Staff later documented repeated unsuccessful attempts to reach the resident after he did not return, and the DON, ADM, RN, and hospice MD all stated the pass process was not followed and the order was vague.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff actions.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
A resident's representative was not informed of a Medicare co-pay upon admission, resulting in a surprise bill. The resident, with cognitive impairments and requiring maximal assistance, was admitted with 21 days of Medicare coverage left. The business office manager failed to communicate the co-pay, and the representative only learned of it after receiving a bill post-transfer.
A facility failed to ensure a resident with epilepsy, Parkinson's disease, and dementia had proper representation for medical decisions after being deemed non-competent. Despite the resident's deteriorating condition and multiple hospitalizations, no conservatorship application was submitted, and the facility relied on two physician signatures on the POLST, contrary to policy. The Director of Nursing acknowledged the need for a conservatorship application.
The facility failed to develop and update comprehensive care plans for two residents, one with a UTI and another with chronic kidney disease on dialysis. The first resident did not have a care plan after being prescribed an antibiotic for a UTI, while the second resident's care plan was not reviewed quarterly, and daily weight monitoring was not implemented. These deficiencies were acknowledged by the facility's staff, including the DON, and were contrary to the facility's policies.
The facility failed to update care plans quarterly for two residents, one with respiratory failure and another with communication issues due to a traumatic brain injury. The care plans were not revised to reflect current interventions, despite the facility's policy requiring quarterly updates and changes in condition. Staff interviews highlighted the potential harm of improper care and communication issues without updated care plans.
A resident with reduced mobility and muscle weakness did not receive proper oral care, as evidenced by a creamy substance on their teeth. Despite the resident's refusal of assistance being noted once, the oral care task spreadsheet inaccurately indicated that care was provided. Staff interviews revealed a lack of proper documentation and reporting of refusals, contrary to facility policy.
A resident with respiratory failure was not receiving continuous oxygen therapy as prescribed, as the oxygen concentrator was found turned off during an observation. The resident had to manually turn it on to receive the prescribed two liters per minute. The LVN and DON confirmed that the concentrator should be checked every shift to ensure proper function, and the failure to do so put the resident at risk for respiratory distress.
The facility failed to ensure accurate medication administration and availability for two residents. A resident's carvedilol bubble pack did not match the physician's hold parameters, risking medication errors. Another resident received metformin late, risking hyperglycemia, and lacked Visine eye drops for eye irritation. The DON confirmed these deficiencies.
A resident with Type II Diabetes Mellitus was not administered metformin within the prescribed time, resulting in a medication error rate of 6.67%. Additionally, Visine-A eye drops were not available when needed for the resident's eye irritation. The facility's policy requires medications to be administered within one hour of their prescribed time, and PRN medications should be available when needed.
A facility failed to properly store and label lorazepam for a resident with anxiety disorder. The medication was found in a medication cart without an opened date label and was not stored in a refrigerator as required by the manufacturer's specifications. The LVN confirmed the medication was not safe to administer due to improper storage, and the DON acknowledged that the medication would not be effective or safe for the resident's treatment.
A facility failed to maintain infection control practices for a resident by allowing a full urinal to be stored on a bedside table with personal items, posing a risk of infection. The resident, with Type II Diabetes Mellitus, required assistance for daily activities. Staff acknowledged the oversight, and the facility's infection control policies were not followed.
The facility did not comply with the requirement that resident rooms hold no more than four residents, as observed in four rooms. A resident and a CNA confirmed adequate space for privacy and care activities, including using a Hoyer lift. However, the facility's policy requires a waiver for rooms exceeding four residents, and a waiver was approved for these rooms, suggesting a potential oversight in policy compliance.
Medication Storage, Expired Supply, and Hazardous Drug Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications and supplements in the Station 2 Medication Cart and Station 2 Medication Room. During observation and interview, three unopened latanoprost ophthalmic solution vials were found in the medication cart without an open date and not stored in the refrigerator, one opened Humulin R vial in the cart had no open date, and an opened bottle of vitamin C tablets remained in the cart even though it was expired. Also found in the cart were Microdot Glucose Gel and Boost Breeze, both expired. In the medication room refrigerator, three unopened insulin aspart flexpens were found after the order had been discontinued and after the medication had expired. The report states that the facility’s policies required medications needing refrigeration to be kept refrigerated, opened containers to be dated, and expired or discontinued medications to be removed from active supply and destroyed. LVN 5 stated the latanoprost should have been refrigerated when received, the Humulin R and latanoprost should have had open dates, and the expired vitamin C, glucose gel, Boost Breeze, and insulin aspart should have been removed from storage. The DON stated expired medications should have been removed from storage before expiration and that latanoprost should have been refrigerated to maintain quality. The DON also stated the Humulin R should have had an open date so staff could determine when to discard it. The facility also failed to ensure hazardous drug handling instructions were present for bicalutamide given to Resident 4. Resident 4 was admitted with diagnoses including benign prostatic hyperplasia and had a G-tube. During medication administration observation, LVN 3 removed bicalutamide 50 mg from the bubble pack, placed it in a plastic bag, and crushed it without wearing gloves. The pharmacy label and eMAR did not indicate that gloves or hazardous drug handling procedures were required. The facility’s hazardous drug guide listed Casodex (bicalutamide) as a hazardous medication with instructions that crushing was not allowed and that chemo-rated gloves should be worn when handling hazardous medications.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen. During observation, a medium container of tomato sauce was found in the walk-in refrigerator with a use-by date of 1/29/2026, and Cook 1 stated it should have been discarded because expired foods could cause sickness in residents who received food from the facility kitchen. The Dietary Supervisor later discarded the tomato sauce after confirming that food was to be used or discarded by its date. A package of raw ground beef was also observed in the walk-in refrigerator with no thaw date. Cook 1 stated the beef had been removed from the freezer the previous day to thaw and staff forgot to label and date it, and the Dietary Supervisor stated all food had to be labeled and dated. The thawed beef was discarded during the observation. Facility policy stated thawed uncooked meat was to be used within 2 days and refrigerated or frozen food taken from the original packing box needed to be labeled and dated. In the food preparation area, the can opener blade was observed to be worn, stained, and covered with sticky and dry brown residue. The Dietary Supervisor verified the residue and worn blade and stated the can opener needed to be washed and the blade replaced to prevent cross contamination of canned food. In Nurses' Station 2, apple sauce used for crushed medications was observed on two medication carts at room temperature and not on ice; LVN 3 and LVN 2 stated it had been delivered from the kitchen that morning and had been used for longer than 4 hours. The Dietary Supervisor and DON stated the apple sauce should have been on ice, and the DON verified that the apple sauce on medication cart 2 was not on ice.
Overfilled dumpster bins left uncovered
Penalty
Summary
The facility failed to ensure trash stored in the dumpster area was maintained in a sanitary manner when two of two trash bins were observed overfilled with the lids open. During an observation in the main dumpster area outside the kitchen back door, the trash bins were pushed back against a wall and the lids were not closed. The Dietary Supervisor stated the trash should have been covered to not attract pests to the area, and the Housekeeping Supervisor stated the bins were pushed back against the wall and the lids were not accessible to close. During interviews, the Central Supply Manager stated trash was picked up every day except Sundays and Tuesdays and that the lids had to be closed at all times because all facility deliveries passed through the trash area. The Maintenance Supervisor also stated the lids had to be closed to prevent pests from going into the trash and eating it, and noted the lids were pushed all the way back to the wall so staff could not close them. The facility policy required garbage and rubbish containers to have tight-fitting lids or covers and to be kept covered when stored or not in continuous use, and the FDA Food Code required outside refuse receptacles to be kept covered and stored so they were inaccessible to insects and rodents.
Failure to Obtain Informed Consent for Diazepam
Penalty
Summary
The facility failed to inform Resident 54 in advance of the risks and benefits of diazepam, a psychoactive medication, before it was ordered and given for muscle spasms. Resident 54 was originally admitted on 4/9/2024 and readmitted on 1/14/2026 with diagnoses including other seizures, other muscle spasm, hepatic encephalopathy, and sequelae of cerebral infarction. The record review showed Resident 54 had the ability to make himself understood and to understand others, and a progress note documented continuous body muscle spasms with diazepam 2 mg given as needed for tremors on 1/9/2026. The order summary showed a telephone order for diazepam 2 mg orally every 8 hours as needed for muscle spasm dated and started on 1/14/2026. However, the resident’s physical and EMR records did not contain an H&P, physician progress notes, consent for diazepam, or documentation of capacity to understand and make decisions. During interviews, LVN 1 and RN 2 stated the informed consent form was not signed by the prescriber or by the resident’s representative, and the facility’s MR could not find any consent for diazepam. Resident 54’s family member stated no one from the facility discussed the informed consent for diazepam, and the DON stated the physician should have obtained informed consent from the resident or representative before giving diazepam and that the facility did not follow its Resident Rights policy.
Failure to Provide Communication Supports and Appropriate Call Light
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three sampled residents by not providing appropriate communication supports and a suitable call light. The deficiency involved Resident 12, Resident 53, and Resident 74, and the report states these failures had the potential to delay the delivery of necessary care. Resident 12 was readmitted with diagnoses including dementia, type 2 DM, HTN, schizophrenia, and bipolar disorder. The MDS identified Korean as the resident’s preferred language and documented severely impaired cognition, along with substantial or maximal assistance needs for multiple ADLs. The care plan identified a communication problem, noted that the resident’s primary language was Korean, and included an intervention for staff to provide a visual and Korean communication board. During observation in the resident’s room, no Korean communication board was present at the bedside. The IP confirmed the resident’s primary language was Korean, observed the resident responding in a language other than English, and stated there should have been a communication board at the bedside. The DON also stated residents should have communication boards in the room if they spoke another language. Resident 74 was admitted with diagnoses including Parkinson’s Disease and metabolic encephalopathy. The care plan identified hearing problems related to hearing loss and included an intervention to provide a communication board as needed. The MDS documented minimal difficulty hearing. During observation in the doorway of the resident’s room, Resident 74 did not have a communication board in the room. Staff stated the resident understood a little English and that communication boards were important for residents who spoke two languages. The DON stated residents were to have communication boards in the room if they spoke another language and that Resident 74 would be at risk for not being able to communicate needs. Resident 53 was admitted and readmitted with multiple diagnoses including acute respiratory failure with hypoxia, lack of coordination, osteoarthritis of the left hand, metabolic encephalopathy, rheumatoid arthritis, glaucoma, dementia, blindness in one eye, low vision in the other eye, and ataxia. The care plan addressed vision problems and included teaching the resident how to locate and use the call light, but it did not specify how the instruction would be provided. The ophthalmology note stated the resident was unable to open his eyes, with left corneal opacity and a right cataract. The MDS documented highly impaired vision, severe cognitive impairment, limited ROM in an upper extremity, and extensive assistance needs. During observation, the resident had a push button call light next to the bed, but he did not respond when asked if he could push it for help and did not move his hand or fingers. CNA 2 stated the resident could not use the call light and could not speak out, and RN 2 stated a push pad call light would have been ideal. The DON stated a resident with limited ROM, blindness, and dementia would not have been able to use a traditional call light button and that a push pad call light would be more appropriate.
Resident Medical Information Left Visible on Medication Cart Screen
Penalty
Summary
The facility failed to keep one resident’s medical information private and confidential when a computer screen on a medication cart was left on and unattended in the hallway near Station 2. During observation, the screen was facing the public hallway and displayed the resident’s name, date of birth, physician name, room number, code status, allergy information, and physician orders, including blood pressure monitoring for a PRN clonidine order, pain monitoring every shift, MiraLAX 17 gram oral packet, and ondansetron HCl 4 mg oral tablet. During the same observation, an LVN was seen working at the nurses’ station while the medication cart screen remained open to public view. The LVN stated she was unaware the screen was open and said the computer screen should not have been open for public view because of the information displayed. The DON later stated resident information should always be kept private and that the computer screen should not have been left open to public view. Facility policies on resident dignity, personal privacy, and medication administration indicated that protected health information, including MARs and TARs, should be secured and covered.
Informed Consent Not Properly Obtained for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of Risperidone for a resident who did not have the capacity to make health care decisions. The resident was re-admitted with diagnoses including dementia, gastrostomy, and schizophrenia, and the history and physical documented that the resident lacked capacity to make complex health care decisions, although she could make her needs known and decide on activities of daily living. The resident’s MDS later showed severe cognitive impairment with a BIMS score of 4 and identified Vietnamese as the preferred language. The resident had a physician order for Risperidone 2 mg via g-tube at bedtime for schizoaffective disorder with derogatory auditory hallucinations. The facility’s informed consent verification form indicated that consent for the medication was obtained from the resident. The resident received multiple doses of Risperidone across the reviewed MARs, and behavioral management team psychotropic medication reviews documented continued use of the medication, with no change in behavioral symptoms at one review and increased behavioral symptoms at another. Those reviews also stated that GDR was contraindicated because the resident’s behavior persisted, but they did not indicate that the resident’s capacity for making health care decisions was reviewed. During interviews, RN 2, LVN 3, the MDS coordinator, and the DON each stated that the resident was confused, did not have the capacity to make medical decisions, and should not have been the person giving informed consent for Risperidone. They stated that consent would normally be obtained from a family member, friend, or through the aging department or IDT process when a resident lacked capacity, and they acknowledged that this did not occur for this resident. The resident was interviewed with an interpreter but did not answer questions about Risperidone and repeatedly stated that she was cold. The facility policies reviewed described a process for obtaining decisions through a resident representative or IDT when a resident lacks health care decision-making capacity, and the psychotropic medication policy stated that residents or representatives have the right to decline psychotropic treatment and should be informed of risks, benefits, and alternatives.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Survey Agency and the ombudsman within 2 hours after a resident developed an acute fracture of the left distal fibula. The resident was admitted with multiple diagnoses including hemiplegia, hemiparesis, dementia, adult failure to thrive, type 2 DM, osteoarthritis, history of falling, age-related osteoporosis, and major depressive disorder. The resident’s MDS indicated moderately impaired cognition and dependence on staff for multiple activities of daily living, including toileting hygiene, bathing, dressing, footwear, and personal hygiene. On 1/27/2026, staff noted left ankle swelling, moderate pain, and bluish discoloration during a morning assessment. The ankle was stabilized, tramadol was given for pain, and the physician was notified. An x-ray was ordered and completed the same day, and the radiology interpretation identified an acute fracture of the left distal fibula. The x-ray results were later faxed to the physician, and the resident was transferred to a hospital for further evaluation and treatment. Facility staff and leadership stated they did not know how the fracture occurred. LVN 3 stated the resident did not fall and that she did not report the injury because it was not abuse. RN 2 stated he did not report the fracture to the SSA or ombudsman and acknowledged it should have been reported as an unusual occurrence and injury of unknown origin. The DON stated she investigated and found no fall or rough handling, confirmed the fracture was an injury of unknown origin, and confirmed it was not reported to the SSA or ombudsman. The Administrator also stated the injury should have been reported immediately once it was found. The facility policy stated injuries of unknown source are to be reported immediately, but not later than 2 hours when serious bodily injury is involved.
Unsafe Handling of Hazardous Medications During G-tube Administration
Penalty
Summary
The facility failed to follow safe hazardous drug handling procedures before preparing and administering hazardous medications for a resident with diagnoses that included benign prostatic hyperplasia and attention to gastrostomy. The resident’s record showed he was admitted to the facility on 6/17/2024 and later readmitted, and his MDS indicated he was dependent on staff for multiple activities of daily living and that eating was not attempted due to medical condition or safety concerns. During a concurrent observation and interview, an LVN prepared seven medications for administration via G-tube. The LVN removed bicalutamide 50 mg from its bubble pack without gloves, placed it in a small transparent plastic bag, and crushed it without wearing gloves. The LVN also removed finasteride 5 mg from its bubble pack, placed it in a small transparent plastic bag, and crushed it while wearing gloves. The LVN stated she wore gloves for finasteride because she could touch it accidentally, but did not wear gloves when removing bicalutamide because she was not going to touch the tablet. The medication labels showed bicalutamide with directions to take one tablet by mouth daily with an additional note that the chart had changed, and finasteride with directions to take one tablet by mouth daily and to use gloves when handling. The LVN stated the cards indicated by mouth but the order had been changed in the eMAR to indicate by G-tube. She then removed her gloves and continued crushing the remaining medications. Later, the LVN stated she had researched Casodex and finasteride and recognized both as hazardous medications, and the DON stated the facility did not have the necessary chemotherapy gloves or gowns to aid in safe preparation and administration of hazardous drugs. The facility policy titled USP Chapter <800>: Hazardous Drug identified Casodex and finasteride on its hazardous medication list and stated to always wear chemo-rated gloves when handling hazardous medications and not to crush, split, or open hazardous tablets or capsules unless pharmacy-approved containment is used.
Failure to Obtain PT Evaluation Before Right Knee Splint Use
Penalty
Summary
The facility failed to provide a PT evaluation for one resident with ROM limitations after a decline in right knee ROM was identified on the quarterly Joint Mobility Assessment. Resident 14 had been admitted with diagnoses including hemiplegia following nontraumatic intracerebral hemorrhage, dysphagia, aphasia, and contractures of the left elbow, left hand, both knees, and left ankle. The admission record also showed the resident had significant ROM limitations on the left side, while the right shoulder, elbow, wrist, hand, hip, knee, and ankle were within functional limits on the earlier JMA. On the quarterly JMA, the resident’s right knee was documented as always being in a bent position, and the resident was noted to benefit from a right knee extension splint to prevent tightness or contracture. A physician’s order was then written for the RNA to perform gentle PROM to both legs and apply both knee extension splints and the left ankle splint with skin checks every two hours. Later orders continued splint use and PROM for the resident’s left arm and both legs. During observation, the resident was seen with the right leg bent at the knee, and the RNA performed exercises and applied the right knee splint. The DOR stated that the standard for providing a splint included screening for changes, obtaining a physician order for therapy services, and completing a PT evaluation to establish goals for splint wear tolerance, monitor the skin, and train the RNA on splint application. The DOR reviewed the resident’s PT evaluation history and did not find a PT evaluation after the decline in right knee ROM was identified. The facility’s Joint Mobility Screen policy stated that therapy would complete the screen for residents with functional change and that the physician would be contacted for therapy orders if a PT evaluation was recommended.
Uncapped enteral feeding tube exposed to air
Penalty
Summary
The facility failed to ensure that Resident 14’s enteral feeding tube was capped while connected to the enteral feeding bag. Resident 14 was admitted and later readmitted with diagnoses including esophagitis, gastrointestinal bleeding, aphasia, gastric ulcer, dysphagia, and moderate protein-calorie malnutrition. The MDS dated 11/10/2025 indicated the resident usually had the ability to understand others and usually had the ability to make himself understood, while the H&P dated 1/10/2026 stated the resident did not have the capacity to understand and make decisions. An order summary dated 2/2/2026 showed physician orders for Jevity 1.5 cal at 70 ml/hr for 20 hours via GT. During a concurrent observation and interview, the resident’s enteral feeding tube connected to the feeding bag was observed uncapped and exposed to the air. LVN 2 stated the exposed tube could create potential for infection and that the entire enteral feeding bag, including the tubing, would need to be changed. The IP stated the exposed tube could become a source of infection and the enteral feeding bag including the tubing would need to be changed to prevent possible spread of infection. The DON reviewed the facility’s Enteral Feedings - Safety Precautions policy and stated the facility did not follow its policy.
Medication Order Missing Frequency and PRN Lidocaine Patch Not in Stock
Penalty
Summary
Pharmaceutical services failed to meet resident needs when a physician order for famotidine for a resident with GERD did not include a frequency. The resident’s admission record showed a history of GERD without esophagitis, and the MDS indicated intact cognition. The order summary listed famotidine 40 mg, 1 tablet by mouth as needed for GERD, but the MAR review showed the medication was not administered during the reviewed period. During interview and record review, the LVN stated the order was missing the frequency and that this created uncertainty about how often the medication should be given. The DON stated medication orders must include dose, route, frequency, and patient name, and that the order should have been clarified with the physician. Pharmaceutical services also failed when lidocaine 4% patches ordered for another resident were not available in stock at the facility. The resident was admitted with diagnoses including aftercare following surgical amputation, right below-knee amputation, osteomyelitis of the thoracic spine, type 2 DM with diabetic neuropathy, and CKD stage 3A. The H&P indicated the resident had capacity to understand and make decisions, and the MDS indicated intact cognition. The order summary listed lidocaine 4% patches for right BKA site pain and lower back pain, but the MAR showed no documented administration of the patches during the reviewed periods. During interview, an LVN stated the facility did not have the lidocaine 4% patch in stock because it was prescribed as needed, and another LVN stated the facility had requested the medication from the pharmacy but had not received it yet. The LVN also stated it had been 8 days since the request and that follow-up with the pharmacy was important. The DON stated medications prescribed on an as-needed basis should have been in stock at the facility regardless of the type of medication, and that nursing staff should have followed up with the pharmacy every day when the lidocaine patch was not in stock.
Failure to Ensure Staff Wore Required Face Masks During Respiratory Virus Season
Penalty
Summary
The facility failed to maintain infection control measures to prevent the spread of infections by not ensuring staff wore full PPE, including a face mask covering both the nose and mouth, during flu season in accordance with its Respiratory Virus Prevention and Control Plan updated on 11/21/2025. During an interview, the Infection Prevention Nurse stated that facility staff needed to wear face masks while inside the facility because of the current flu and COVID-19 season, and later stated staff were required to wear masks inside the facility to protect residents from respiratory viruses and should definitely wear a face mask while inside resident rooms. During an observation, CNA 1 was seen sitting in a resident room without wearing a face mask, and during a concurrent observation and interview in the same room, CNA 1 was again observed without a face mask. CNA 1 stated another CNA was assigned to the room and was at lunch, and stated she had returned from lunch and went straight to the room to relieve the other CNA. The DON stated the facility required staff to wear face masks during flu season, and the IPN and DON both confirmed that staff were required to wear masks inside the facility. Review of the facility’s in-service attendance log and Respiratory Virus Prevention and Control Plan showed that residents were at increased risk for severe disease, hospitalization, death, and outbreaks caused by COVID-19, influenza, and other respiratory viruses, and that source control masking was to be used during periods of increased community transmission.
Excess Residents in Multiple Shared Rooms
Penalty
Summary
The facility failed to ensure four of 38 resident rooms met the requirement of no more than four beds per room. The deficiency involved room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER], which were identified in the facility’s Room Variance Waiver Request dated 2/4/2026. The waiver request stated the facility was seeking approval for these rooms and asserted there was enough space to provide each resident’s care, dignity, privacy, and that the rooms were in accordance with the special needs of residents. During observations, room [ROOM NUMBER] appeared to have enough space for therapy and nursing services, and LVN 3 stated there was enough space for therapy, maneuvering, and nursing services. Room [ROOM NUMBER] was observed to have enough space for therapy, resident activity, and nursing services, and CNA 1 stated there was enough space to perform therapy and provide services. Staff were also observed assisting residents in room [ROOM NUMBER], with enough room to provide services, and Resident 13 stated he had no complaints about the size of room [ROOM NUMBER] with five beds. The facility’s policy and procedure titled Resident Room Size, dated 1/2025, stated residents would have at a minimum of 80 square feet of living space and no more than 4 residents to a room, and any room not meeting the requirements would require an annual room waiver request to CDPH.
Failure to Provide Ordered Wheelchair Safety Devices and Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents at risk for falls were provided with ordered and care-planned safety devices, specifically wheelchair footrests, a wheelchair alarm, and a floor mat. Resident 1 was admitted with diagnoses including degeneration of the brain, dementia, weakness, and bilateral knee osteoarthritis, and had an MDS showing severely impaired cognition and a need for maximal assistance with most ADLs and locomotion on and off the unit. Resident 1’s orders included use of a wheelchair alarm when up in the wheelchair to alert staff if attempting to get up unassisted, and a floor mat on the right side of the bed to prevent injury from any fall. Despite these orders, observation and staff interview revealed that Resident 1’s wheelchair did not have footrests or a wheelchair alarm, and there was no floor mat in the room. Resident 2 was admitted with weakness, osteoporosis, and Alzheimer’s disease, and also had an MDS indicating severely impaired cognition and a need for maximal assistance with transfers, including sit-to-stand and chair/bed transfers, and supervision or partial assistance with other ADLs. The comprehensive care plan indicated a need for maximal assistance with locomotion on and off the unit. Physical therapy staff indicated that Resident 2 should have a footrest due to recent hospitalization, current weakness, and ongoing therapy three times a week. However, during observation in the activity room, Resident 2 was seated in a wheelchair without footrests. During the same observation in the activity room, both Resident 1 and Resident 2 were seen sitting in wheelchairs without footrests. The activity assistant present stated he had not been trained in transferring residents in wheelchairs and did not know why the residents did not have footrests. A CNA confirmed that Resident 1’s wheelchair lacked footrests and an alarm, and that there was no floor mat in the room, and began searching for the footrests. The QA nurse and MDS nurse both stated that residents with weakness, hemiplegia, or fall risk should have footrests, and that ordered alarms and floor mats should be implemented to ensure safety. The facility’s fall management policy stated that staff, in conjunction with the attending physician, will identify and implement appropriate interventions to reduce fall risk and minimize serious consequences of falling, but the ordered and recommended safety devices were not in place for these residents.
Delayed Reporting of Resident Elopement
Penalty
Summary
The facility failed to report a resident’s elopement/missing-person event to CDPH, the Ombudsman, and local law enforcement within the timeframe required by its policy. Resident 1 left the facility on pass on 10/7/2025 at 12:50 PM and did not return. The facility’s policy titled Elopement, dated 1/2025, required police notification if a resident could not be located within 15 minutes and reporting to CDPH, but the facility did not notify the outside agencies until 10/8/2025 at about 3 PM, delaying the onsite inspection and investigation. Resident 1 was admitted on 6/11/2025 with diagnoses including end stage heart failure, dilated cardiomyopathy, chronic kidney disease stage 2, acute pulmonary edema, cocaine abuse, and hospice status. The resident’s care plan identified a risk for elopement and falls and directed staff to monitor whereabouts frequently, document wandering behavior, and attempt diversional activity. The H&P dated 9/7/2025 indicated the resident had capacity to understand and make decisions, and the MDS dated 9/15/2025 indicated the resident could make himself understood and understand others, but required assistance or supervision with several activities of daily living. Progress notes showed the resident left on pass and did not return, with repeated unsuccessful attempts by staff to contact him on 10/7 and 10/8. A late-entry note documented that RN 2 informed the emergency contact, called the police, and notified the Ombudsman, but this was entered later and the facility’s fax confirmations showed CDPH and the Ombudsman were not notified until 10/8/2025 in the mid-afternoon. Interviews with LVN 2, RN 2, RN 1, the DON, and the ADM confirmed staff did not follow the facility’s elopement policy and that there was disagreement among staff about when the resident should have been considered missing.
Missing care plan for out on pass order
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for a resident’s out on pass physician’s order. Resident 1 was admitted with diagnoses including end stage heart failure, dilated cardiomyopathy, chronic kidney disease stage 2, acute pulmonary edema, cocaine abuse, and hospice status. The resident’s H&P documented that he had capacity to understand and make decisions, and the MDS indicated he could make himself understood and understand others. The MDS also showed he required supervision or touch assistance for walking 10 feet, toileting, oral hygiene, and eating, and moderate to partial assistance for showering/bathing, putting on shoes/socks, personal hygiene, and tub/shower transfers. The Order Summary Report showed an order for Resident 1 to go out on pass starting 10/1/2025. During interview and record review, LVN 2 verified that Resident 1 did not have a care plan for being out on pass and could not locate the IDT assessment required by the facility’s policy. LVN 2 stated the facility should have done an IDT. RN 1 also verified that Resident 1 did not have a care plan for out on pass and stated that without following the policy, the facility would not be able to assess Resident 1’s safety and the IDT would need to determine the resident’s ability to go out on pass.
Unsupervised Out on Pass and Missing Resident Management Failure
Penalty
Summary
The facility failed to ensure a resident who required supervision with walking and was on hospice care was properly assessed and managed for out on pass activity. The resident was admitted with end stage heart failure, dilated cardiomyopathy, chronic kidney disease stage 2, acute pulmonary edema, cocaine abuse, and non-compliance with treatment. The care plan identified the resident as a risk for elopement and falls and directed staff to monitor his whereabouts frequently, document wandering behavior, and attempt diversional activity. The resident’s H&P stated he had capacity to understand and make decisions, and the MDS showed he could make himself understood and understand others, but also that he required supervision or touch assistance for walking 10 feet, toileting, oral hygiene, and eating. The resident was sent out on pass without an IDT meeting documented in collaboration with hospice, without a care plan for going out on pass, and without a physician order specifying whether he needed to be accompanied by a responsible person or supervised while out. The hospice doctor stated he was not aware the resident had an out on pass order, had not been invited to participate in an IDT meeting, and would not have allowed the resident to go out independently. He stated the resident should have been accompanied by a responsible party and should not have been out longer than four hours. The facility’s policy required the IDT to assess the resident’s ability to participate in activities outside the facility, the attending physician to review that assessment, and the physician’s order to state whether accompaniment was needed. After the resident left the facility, staff did not have an agreed upon return time and did not provide medications upon departure, including carvedilol that the DON later stated should have been given because the resident could have had a heart issue without it. Staff attempted to contact the resident multiple times over the next several days without success, and the resident had not returned. Interviews showed staff were uncertain about when to consider the resident missing and did not follow the facility’s out on pass and elopement policies. The ADM, DON, RNs, LVNs, CNA, and SSD all described that the resident left unsupervised, did not return as expected, and that the facility did not follow its own policy for assessing and managing the resident’s out on pass status.
Out on Pass Order Was Not Properly Evaluated or Clarified
Penalty
Summary
The facility failed to follow its Out on Pass policy and its Physician Orders and Telephone Orders policy for Resident 1, who was admitted with end stage heart failure, dilated cardiomyopathy, chronic kidney disease stage 2, acute pulmonary edema, cocaine abuse, non-compliance with medical treatment, and hospice services. The record showed Resident 1 was identified as a risk for elopement and falls, and the care plan directed staff to monitor the resident’s whereabouts frequently, document wandering behavior, and attempt diversional activity. The resident’s H&P documented that he had capacity to understand and make decisions, and the MDS showed he could make himself understood and understand others, but also required assistance or supervision with multiple activities of daily living. The record showed an order for Resident 1 to go out on pass starting 10/1/2025, and a progress note on 10/6/2025 documented that he went out on pass on 10/7/2025 at 12:50 PM. Facility documentation then showed the resident had not returned and staff attempted to contact him multiple times on 10/7/2025, 10/8/2025, and 10/9/2025 without success. The notes also stated the Social Services Director had been trying to reach the resident since 10/7/2025 at 3:07 PM. During interviews, facility staff stated they could not find an IDT assessment for the resident’s out on pass, and RN 1 stated the facility did not perform an IDT meeting to assess the resident’s safety and ability to go out on pass. RN 1 also stated the order to go out on pass was not clear and did not include an agreed upon return time. The DON and ADM stated the facility did not follow its out on pass policy, did not create a care plan for the pass, did not provide medications when the resident left, and did not have an agreed upon return time. The hospice doctor stated he was not aware of the out on pass order, would not have allowed the resident to go out independently, did not know the resident had a car or could drive himself, was not invited to participate in an IDT meeting, and stated the resident should have been accompanied by a responsible party and should not have been out for longer than four hours.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision measures were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Inform Resident's Representative of Medicare Co-Pay
Penalty
Summary
The facility failed to inform a resident's representative about the Medicare co-pay upon admission, leading to a surprise bill. The resident was admitted with diagnoses including pneumonia, adult failure to thrive, dementia, and anxiety. The Minimum Data Set indicated the resident's cognition was not intact, and they required maximal assistance with daily activities. Upon admission, the business office manager ran a Medicare eligibility report, which showed the resident had 21 days of coverage left with a co-pay of $209.50 per day. However, this information was not communicated to the resident's representative. The resident's representative attended an interdisciplinary team meeting via phone, where the social services assistant believed the resident's stay was completely covered. The business office manager was not part of this meeting and did not inform the representative of the co-pay. The representative only learned of the co-pay after receiving a bill in the mail following the resident's transfer to another facility. The facility's policy requires reviewing financial obligations with residents or their representatives upon admission, which was not adhered to in this case.
Failure to Ensure Proper Representation for Non-Competent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was deemed non-competent, had proper documented representation to make medical decisions. The resident, who had diagnoses including epilepsy, Parkinson's disease, and dementia, was admitted without a conservatorship application despite being unable to understand and make decisions. A review of the resident's records showed that a public guardian was initially assigned to investigate the need for conservatorship in 2015, but no petition was filed due to a lack of imminent need. However, by 2020, the resident's condition had deteriorated, and they were unable to make decisions, yet no new application for conservatorship was submitted. Interviews with facility staff revealed that the resident had been hospitalized multiple times in 2024 and returned to the facility in a nonverbal and nonresponsive state. Despite this, the facility relied on two physician signatures on the resident's POLST to make decisions, which was not in line with the facility's policy for representation. The Director of Nursing acknowledged that a conservatorship should have been applied for when the resident was deemed non-competent. The facility's policy indicated that legal authority for health care decisions should include a court-appointed legal guardian or conservator, which was not in place for this resident.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to potential delays or lack of care. For one resident with a urinary tract infection (UTI), the facility did not create a care plan after the resident was prescribed Macrobid, an antibiotic for UTI, following a change in condition. The Quality Assurance nurse and the Director of Nursing both acknowledged that a new care plan should have been initiated when there was a change of condition or a new medication order. The facility's policy required care plans to be revised as changes in the resident's condition dictate and reviewed at least quarterly. Another resident with chronic kidney disease and on renal dialysis had a care plan that was not reviewed quarterly, and the intervention to monitor daily weight gain was not implemented. The Registered Nurse Supervisor noted that the facility only had monthly and post-dialysis weights, not daily weights as required by the care plan. The Director of Nursing confirmed that the care plan was last revised over a year ago and should have been updated. The facility's policy indicated that care plans should be reviewed quarterly to enhance resident function and prevent declines.
Failure to Update Care Plans Quarterly for Two Residents
Penalty
Summary
The facility failed to ensure that the oxygen care plans for two residents, Resident 35 and Resident 38, were reviewed and revised quarterly to reflect their current status and interventions. Resident 35 was admitted with diagnoses including respiratory failure, acidosis, and heart failure. The care plan for Resident 35, revised on December 1, 2023, included interventions such as elevating the head of the bed and providing oxygen as ordered. However, the care plan was not updated quarterly as required, despite the resident being on continuous oxygen therapy. The Director of Nursing acknowledged the importance of updating care plans to facilitate resident-centered care. Resident 38, admitted with a history of traumatic brain injury and acquired deformity of the head, had a care plan related to communication problems last revised in April 2021. Observations indicated that Resident 38 communicated using a Spanish communication board and required assistance from a CNA for interpretation. The Quality Assurance Nurse noted that the care plan had been revised in December 2024, but the revision date was not reflected in the care plan. The Information Technologist explained that the revision date would only change with a doctor's order or a change in condition. Interviews with facility staff, including the MDS Nurse and the Registered Nurse/Nursing Supervisor, highlighted the potential harm to residents without updated care plans, such as improper care and communication issues. The Director of Nursing reiterated the policy that care plans should be revised quarterly, as needed, and when there is a change in condition. The facility's policy emphasized the need for the Interdisciplinary Team to review and update care plans in response to changes in condition, unmet desired outcomes, readmissions, and quarterly assessments.
Failure to Provide Proper Oral Care
Penalty
Summary
The facility failed to ensure proper oral care for Resident 69, who was admitted with diagnoses including reduced mobility, muscle weakness, and age-related physical debility. The resident was alert and oriented, requiring substantial assistance with oral hygiene. During observations, a creamy substance was noted on the resident's teeth, indicating inadequate oral care. Despite the resident's refusal of assistance on one occasion, the oral care task spreadsheet indicated that oral care was performed, but the refusal was not properly documented. Interviews with staff revealed inconsistencies in the documentation and reporting of oral care refusals. CNA 2 acknowledged that the resident refused oral care once, but this was not accurately reflected in the records. LVN 1 and the DON confirmed that refusals should be documented and reported, but this was not done. The facility's policy required documentation of mouth care and notification of supervisors in case of refusal, which was not adhered to, leading to the deficiency.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received continuous oxygen therapy as prescribed by the physician. The resident, who was admitted with diagnoses including respiratory failure with hypoxia, acidosis, and heart failure, was supposed to receive two liters of oxygen per minute via nasal cannula continuously. However, during an observation, it was noted that the oxygen concentrator was not turned on, and the resident had to manually activate it to receive the prescribed oxygen flow. Interviews with the LVN and the DON revealed that the oxygen concentrator should be checked at the beginning of every shift to ensure it is functioning properly. The LVN acknowledged that the resident could become hypoxic if the oxygen was not administered continuously. The DON confirmed that the LVN was responsible for checking the oxygen concentrators and that the failure to provide oxygen as ordered put the resident at risk for respiratory distress.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to ensure that the carvedilol medication bubble pack for a resident matched the physician's hold parameters for blood pressure. The physician's order indicated that the medication should be held if the systolic blood pressure (SBP) was less than 100 and the heart rate (HR) was less than 60. However, the medication bubble pack indicated hold parameters of SBP less than 110 or HR less than 60. This discrepancy was observed during a medication pass, and the Licensed Vocational Nurse (LVN) acknowledged the mismatch, which could lead to medication errors and blood pressure abnormalities. Another deficiency involved the administration of metformin for a resident with Type II Diabetes Mellitus. The facility's policy required medications to be administered within one hour of the prescribed time. However, the metformin was administered almost an hour late, increasing the risk of hyperglycemia. The Registered Nurse (RN) admitted to the delay and acknowledged the potential risk of hospitalization due to the late administration. Additionally, the facility failed to have Visine eye drops available for a resident who complained of eye irritation. Although the medication was prescribed as needed, it was not available when the resident requested it, leading to potential worsening of eye discomfort. The Director of Nursing (DON) confirmed that the medication should have been available, and the lack of availability could result in eye irritation and redness.
Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during a medication pass for a resident, resulting in a medication administration error rate of 6.67%. The resident, who was diagnosed with Type II Diabetes Mellitus, was not administered metformin within one hour of the prescribed time. The medication was scheduled for administration at 7:30 AM but was documented as administered at 9:23 AM, almost one hour late. This delay was acknowledged by the Registered Nurse/Nursing Supervisor (RNS) 1, who admitted the mistake and recognized the risk of hyperglycemia and potential hospitalization for the resident due to the late administration. Additionally, the resident was not provided with Visine-A eye drops as needed for eye irritation and discomfort, as the medication was not available when requested. The RNS 1 admitted to not having the Visine eye drops available, despite it being a PRN medication, and acknowledged the risk of worsening eye discomfort for the resident. The Director of Nursing confirmed that the facility's policy required medications to be administered within one hour of their prescribed time and that PRN medications should be available for administration when needed.
Improper Storage and Labeling of Lorazepam
Penalty
Summary
The facility failed to ensure proper storage and labeling of lorazepam, a controlled substance, for Resident 19. During an inspection of the Station 3 Medication Cart, it was observed that Resident 19's lorazepam oral concentrate was not labeled with an opened date, which is required by the manufacturer's specifications. The medication was also not stored in a refrigerator as required, which could compromise its effectiveness and safety. The Licensed Vocational Nurse (LVN) confirmed that the medication should have been labeled with an open date and stored in a refrigerator, and acknowledged that the medication was not safe to administer due to improper storage. Resident 19, who was admitted with diagnoses including palliative care and anxiety disorder, was dependent on facility staff for daily living activities and had severely impaired cognition. The Physician's Order Summary Report indicated that lorazepam was prescribed to be administered sublingually as needed for anxiety. However, the absence of proper labeling and storage meant that the medication's expiration could not be determined, potentially affecting the resident's treatment for anxiety and agitation. The Director of Nursing (DON) confirmed that the medication would not be effective or safe to administer under these conditions.
Infection Control Lapse with Resident's Urinal
Penalty
Summary
The facility failed to maintain proper infection control practices for one of the residents, identified as Resident 8, by not ensuring a sanitary environment in the resident's care area. During an observation, a male urinal containing urine was found on the bedside table alongside other personal items such as a drinking water container, a water bottle, and a mobile phone. This situation was noted during a medication administration by a Registered Nurse/Nursing Supervisor (RNS) who acknowledged that the urinal should have been emptied and not stored with other belongings, as it posed a risk for infection and cross-contamination. Resident 8, who was originally admitted in 2009 and readmitted later, had diagnoses including Type II Diabetes Mellitus and required varying levels of assistance for daily activities. The Director of Nursing (DON) confirmed that the Certified Nurse Assistant, housekeeping, and Licensed Vocational Nurse should have ensured the cleanliness and sanitation of Resident 8's care areas. The facility's policies on infection control and standard precautions were reviewed, indicating that all bodily fluids should be managed to prevent infection, but these were not adhered to in this instance.
Non-Compliance with Resident Room Capacity Requirements
Penalty
Summary
The facility failed to comply with the requirement that resident rooms hold no more than four residents, as observed in four sampled rooms. During an observation and interview, a resident in a room with four beds expressed satisfaction with the space available for privacy and family visits. A CNA assigned to the room confirmed there was sufficient space to perform duties, including using a Hoyer lift for a resident. Despite these observations, a review of the facility's policy indicated that rooms should not exceed four residents, and any room not meeting this requirement would need a waiver from CDPH. A waiver request letter dated earlier in the year showed approval for rooms with more than four beds, indicating a potential oversight in ensuring compliance with the room size policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hollywood Presbyterian Medical Center D/p Snf | 0.4 mi | ★★★★★ | 22 | 0 |
| Garden Crest Rehabilitation Center | 0.7 mi | ★★★★★ | 20 | 0 |
| The Meadows On Sunset Post Acute | 0.8 mi | ★★★★★ | 49 | 1 |
| Alexandria Care Center | 0.9 mi | ★★★★★ | 14 | 0 |
| Palazzo Post Acute | 1.2 mi | ★★★★★ | 8 | 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.