Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White Point Care Center during CMS and state inspections, most recent first.
Missing Full-Time DON Oversight: The facility failed to ensure an RN was designated to serve as DON on a full-time basis after the DON quit, leaving the nursing department without the required full-time RN oversight. The facility assessment called for a full-time DON, and interviews with the DSD and Administrator confirmed the DON was responsible for overseeing nursing services and coordinating care.
Improper Storage of Cold Beverages and Opened Ice Cream: The facility failed to keep pre-poured juices at the required cold temperature while trays were being prepared, with apple, cranberry, and orange juice observed at 69.9 degrees Fahrenheit instead of below 41 degrees Fahrenheit. The facility also had an open box of ice cream in the freezer with no use-by date labeled, despite policy requiring use-by dates on opened food.
Staff did not consistently follow infection control precautions for three residents. A resident on EBP had discarded PPE placed in an open trash can instead of a closed container, a CNA entered a resident’s C. diff contact isolation room without gloves and used ABHR instead of soap and water, and another CNA provided direct care to a resident on TBP without the required PPE. The IP and other nursing leaders confirmed the expected PPE and hand hygiene practices for these precautions.
Call Light Left Out of Reach: A resident with dementia, muscle weakness, spinal stenosis, and difficulty walking was observed in bed with the call light on the floor. A CNA entered the room to provide tissues and left without placing the call light within reach, despite the care plan directing that it be kept within easy reach. Staff stated the resident could not reach the call light to summon help, and the ADON said this could delay care and prevent the resident from calling for assistance.
The facility failed to provide SNF ABNs to two residents when Medicare Part A coverage ended, and their representatives were not given written notice of possible financial liability for non-covered skilled services. One resident had Alzheimer’s disease and was unable to make decisions, and the representative reported receiving bills without prior written notice. The BOM acknowledged the notices were not provided, and the ADM stated she was not clear on ABN policy and regulations.
A resident’s MDS did not accurately reflect hearing status or hearing aid use. The MDS showed minimal hearing difficulty and no hearing appliance, but the MDS Nurse later stated she had just learned the resident used hearing aids and that the assessment was not coded correctly. The ADON stated nursing staff were not aware the resident had or used hearing aids.
Failure to Initiate Hearing Loss Care Plan: A resident with encephalopathy, dementia, anxiety, and generalized weakness did not have a care plan initiated and implemented for hearing loss. The chart included an ENT/audiology order, but the MDS documented adequate hearing and no hearing aid use. An LVN and the ADON stated licensed nurses are responsible for initiating and updating hearing-related care plans, and facility policy required a comprehensive person-centered care plan with measurable objectives and timetables.
Failure to Provide Access to Hearing Aids: A resident with dementia and documented hearing loss was not provided access to her hearing aids, which were stored in the SSD’s file cabinet. The resident stated she could not hear when spoken to, a CNA confirmed she had hearing problems and often needed words repeated, and the SSD said the hearing aids were not known to staff, may not have been working, and were supposed to be checked by ENT. The resident’s record and belonging list identified two hearing aids, but staff were unaware she had them.
Failure to complete nursing competency upon hire for an ADON. The DSD confirmed the ADON was hired without the required skills competency evaluation, and the ADON stated she had not had any competencies completed since hire. The facility policy required nursing staff competency evaluations upon hire and annually.
Two residents received lorazepam without the required documented behavior monitoring and clinical justification. One resident was given PRN lorazepam repeatedly for anxiety with no documented anxiety episodes before administration, while another resident with anxiety and sleep difficulty had lorazepam ordered at bedtime without documentation of the behaviors supporting its use. Staff interviews confirmed the medication was being administered without the needed monitoring and documentation.
Medication Error Rate Exceeded 5% During Medication Pass: An LVN failed to administer three ordered supplements—Rena Vite, vitamin C, and zinc sulfate—to a resident during a med pass, resulting in a 10.34% medication error rate. The resident had intact cognition, a stage 3 sacrococcyx PI, and orders for wound-related supplements to support healing.
Failure to follow up on recommended dental services for a resident with impaired cognition and assistance needs for oral hygiene. Dental notes documented heavy tartar and recommendations for cleaning, scaling, root planing, and x-rays, while the resident reported something stuck in his teeth and staff were told about the concern. SSD stated the family agreed to pay out-of-pocket for cleaning, the resident had no dental insurance, and the SSD did not follow up on the dental service; QA stated the resident was at risk for pain and reduced food intake leading to weight loss.
A resident with Parkinson's disease, dementia, anxiety, and DM had moderately impaired cognition and could not make medical decisions. The facility's admission coordinator said the resident's RP signed a binding arbitration agreement, but the RP stated he never signed it and had never been told about it. Staff also acknowledged the agreement should be explained before signing, and the facility policy required it to be explained in language the resident or RP could understand.
Missing Annual Dementia Training for CNAs: The facility failed to ensure all CNAs received the required five hours of annual dementia training. The DSD confirmed only one hour of dementia training had been provided within the last year, while the ADON and ADM stated the training was mandatory for all staff. Facility policy required dementia-specific caregiver training at five hours per year for CNAs and for staff training records to be maintained.
The facility failed to follow its own policy requiring use of a Resident Council Response Form to document and track concerns raised in resident council meetings. In two meetings, residents reported problems with timely toileting assistance and delayed call light response, but these issues were only noted in the council minutes and were not entered on the required response form. The Activities Director was unaware of prior council concerns, and the DON acknowledged knowing about the issues and providing staff in-services but not using the mandated tracking tool, preventing formal follow-up and QAPI review of these resident-reported problems.
A resident with complex medical needs experienced low blood pressure prior to dialysis, but nursing staff failed to reassess vital signs or notify the physician before transport. Additionally, staff did not inform the physician when a foul-smelling odor was observed from the resident's diabetic foot wound, which had worsened. These failures delayed necessary care and increased the risk of hospitalization.
Two residents, both requiring supervision while smoking due to cognitive and physical impairments, were left unsupervised on the smoking patio after the scheduled smoking period. The patio door was not secured, and staff did not monitor or redirect the residents as required by facility policy. During this time, one resident became verbally aggressive and threw a plastic mug at another, causing a head injury and escalating pain. Staff interviews confirmed lapses in supervision and failure to follow established safety protocols.
Three residents with significant medical needs tested positive for COVID-19 on the same day, constituting an outbreak. The facility's Infection Prevention Nurse reported the outbreak to the local health department but failed to notify CDPH, despite facility policy and regulatory requirements. This deficiency was confirmed through record review and staff interviews.
A resident with a Stage 4 pressure ulcer, who was nonverbal and fully dependent, experienced unmanaged pain during wound care and repositioning. Staff observed facial grimacing and moaning but continued treatment without stopping to assess or address pain. Pain medication was not administered as ordered prior to wound care, and staff did not verify or coordinate the timing of medication and treatment, resulting in the resident undergoing procedures without adequate pain relief.
Surveyors identified multiple deficiencies in medication administration and documentation, including late administration of antihypertensive medication, unclarified duplicate topical orders, inaccurate MAR entries, improper handling and administration of ophthalmic and otic medications, and discrepancies in controlled substance documentation. These issues involved several residents with complex medical needs and were confirmed through observation, interviews, and record reviews.
Two residents experienced medication administration errors, including late administration of antihypertensive medication, failure to administer prescribed ophthalmic solutions, and preparation of an incorrect vitamin supplement. In one case, a nurse documented administration of eye drops that were not given, and allowed a resident assessed as unable to self-administer to keep medications at bedside. In another case, a nurse prepared vitamin B complex instead of the ordered thiamin. These actions resulted in a medication error rate above the acceptable 5% threshold.
Surveyors found that staff failed to ensure medication labels matched physician orders, did not label opened insulin pens with the date, left discontinued insulin in the medication refrigerator, allowed eye drops to remain at a resident's bedside despite lack of self-administration assessment, and stored expired naloxone in a medication cart. These actions were not in accordance with facility policy or manufacturer guidelines.
Three residents with complex medical conditions, including DM, HTN, CKD, and dysphagia, reported that the food served was consistently cold, bland, and unappetizing. Observations confirmed that meals were unseasoned, visually unappealing, and sometimes inedible. Food was prepared offsite and delivered in hot carts, but staff only checked for accuracy, not quality or palatability, resulting in dissatisfaction and some residents relying on outside food or personal seasonings.
The facility's QAA and QAPI committees did not implement corrective actions for systemic issues, including untimely call light response, inadequate ADL implementation, medication errors, improper storage and labeling of medications and food, and incomplete clinical records. Leadership acknowledged ongoing problems and the need for improvement, but deficiencies persisted, potentially impacting resident care.
A resident's MDS assessment was incorrectly coded to indicate incontinence, despite documentation and staff interviews confirming the resident was continent and able to communicate needs. The error was identified through review of records and interviews with the resident, CNA, LVN, and MDS nurse, revealing that the resident only used diapers at night due to delayed assistance, not incontinence.
A resident with diabetes, hypertension, and severe cognitive impairment developed a toe infection, but staff did not update or implement a care plan to address the new condition. Despite facility policy and staff acknowledgment that care plans should be revised with significant changes, no care plan interventions or monitoring were documented for the infection.
A resident with impaired cognition and multiple health conditions did not receive Ciprodex otic drops according to professional standards or facility policy. An LVN failed to shake the suspension and administered one drop at a time with five-minute intervals, causing the resident discomfort. Facility policy required all drops to be given at once, followed by a five-minute wait, but incorrect in-service instructions led to the deficiency.
A resident with a Stage 4 pressure ulcer did not receive wound care as ordered, as a nurse applied Santyl ointment instead of the prescribed Medi Honey. The nurse admitted to not verifying the current physician orders before treatment, and records confirmed the deviation from the care plan. This failure to follow the prescribed wound care regimen was confirmed by observation, interview, and record review.
A resident with hypertension and other chronic conditions did not receive their prescribed metoprolol succinate ER within the facility's required 60-minute window on multiple occasions. The medication, scheduled for administration with meals, was repeatedly given late, as confirmed by direct observation, record review, and staff interviews. Facility policy requiring timely medication administration was not followed.
A resident with severe cognitive impairment and limited English proficiency did not have his food preferences, including cultural preferences, identified or honored. The dietary staff supervisor failed to consult the resident's family or representative, resulting in the resident not receiving culturally appropriate meals, despite facility policy requiring such efforts.
A nurse documented the administration of several prescribed eye medications for a resident with glaucoma and other conditions, despite not actually administering them and not having the medications available. The resident was assessed as unable to self-administer medications, and facility policy required accurate documentation by the administering nurse. The DON confirmed that the resident was not reassessed for self-administration and that documentation practices were not followed, resulting in inaccurate medical records.
A LVN did not perform hand hygiene between resident care and when entering or exiting a resident room. The LVN acknowledged this lapse, and the DON confirmed that hand hygiene is required in these situations according to facility policy.
A resident with multiple chronic conditions and severe cognitive impairment was prescribed Doxycycline for toe cellulitis without first obtaining a wound culture or confirming infection criteria, contrary to the facility's Antibiotic Stewardship protocol. Staff interviews and record review confirmed that required steps were not followed before initiating antibiotic therapy.
A resident with multiple chronic conditions was found to have a large hole in the sliding screen door of their room, which had been present for several months without being addressed. The issue was known to the resident and observed by staff, but was not reported or documented for repair in a timely manner, resulting in a failure to provide a safe and home-like environment as required by facility policy.
A resident experienced discomfort due to excessively high room temperatures, reaching 90°F, which violated the facility's policy of maintaining temperatures between 71-81°F. Staff interviews revealed that room temperatures were only checked upon complaints, not daily as required, leading to this deficiency.
A resident with a history of aggressive behavior and severe cognitive impairment physically abused another resident after expressing a preference for solitude and a dislike for noise. The facility failed to provide a private room or adequate monitoring, resulting in the victim sustaining facial injuries and emotional distress.
A resident with dementia and a history of wandering behavior entered her previous room after an alleged altercation with her former roommate, due to the facility's failure to implement care plan interventions. Despite the care plan requiring constant visual checks and hourly monitoring, staff did not document these actions, leading to the resident's unsupervised movement. Surveillance footage confirmed the resident's entry into the previous room, highlighting a lapse in care plan implementation.
A facility failed to provide a resident's medical records to their legal representative within the required 48-hour timeframe. The resident, with severe cognitive impairment and multiple diagnoses, had their records requested on 8/14/2024, but the facility delayed the release until 9/24/2024. The delay was due to the facility's process of routing requests through their legal team, violating the policy of timely record release.
A facility failed to provide a resident's medical records within the required two working days after a request from the legal representative. The resident, with severe cognitive impairment and multiple diagnoses, had their records requested on August 30, 2024, but the facility did not submit them until September 6, 2024. The Medical Records Director and Administrator misunderstood the policy, leading to a violation of the resident's rights.
A resident at high risk for skin breakdown did not receive proper pressure ulcer care and prevention. The facility failed to measure existing wounds upon admission and delayed ordering a low air mattress, leading to the development of new ulcers and worsening of existing ones. Staff interviews confirmed non-compliance with facility policies on wound assessment and intervention.
A resident with bone cancer and congestive heart failure experienced a change in condition, requiring a breathing treatment that delayed an infusion appointment. The facility failed to notify the resident's representative of this change, violating the resident's rights. Staff interviews and facility policy confirmed the requirement for notifying and involving the representative in care planning.
A resident with bone cancer did not receive proper pain management as the facility failed to document the administration of Norco, assess pain using a rating scale, and evaluate the medication's effectiveness. The Controlled Medication Count Sheet showed Norco was given, but it was not recorded in the MAR. Nursing notes inaccurately documented the effectiveness of the medication at the time of administration. Staff interviews confirmed these documentation lapses, which did not comply with the facility's pain management policy.
A resident with severe cognitive impairment and a history of falls did not have floor mats at the bedside as required by their care plan. The absence of these mats was confirmed during an observation and interview with the Charge Nurse, who acknowledged the oversight. The facility's policy mandates comprehensive care plans to maintain residents' well-being, which was not followed in this case.
A resident with severe cognitive impairment refused podiatry and optometry services, and the facility failed to update the care plan or notify the family, as required by policy. This led to a delay in necessary services, potentially impacting the resident's health.
A resident with severe cognitive impairment and high fall risk did not have floor mats placed by their bed as ordered by the physician and indicated in the care plan. Despite the resident's history of falls and a high Morse Fall Scale score, the necessary safety measures were not implemented, posing a risk of severe injury.
The facility failed to maintain the dignity and privacy of two residents. One resident was left in a urine-soaked diaper without a privacy curtain, and another had an exposed urinary catheter without a privacy bag. Staff confirmed these were dignity issues.
The facility failed to ensure that the call light was within reach for two residents, leading to frustration, feelings of helplessness, and increased risk of falls and injuries. Both residents had significant medical conditions and required assistance with daily activities, but their call lights were not accessible, contrary to facility policy.
The facility failed to provide two residents with their preferred activities, negatively impacting their quality of life. One resident with cerebral infarction was observed multiple times without engagement in her preferred activities, while another resident with dysphagia and hemiplegia was mostly found sleeping without any activity personnel engaging her. Staff interviews confirmed the inconsistency in providing activities due to staffing issues.
The facility failed to ensure proper respiratory care for two residents. One resident's suction machine tubing and yankauer were not dated, and another resident's oxygen tubing was undated, with humidifying water not changed since 4/7/2024. Staff confirmed these items should be changed weekly to ensure patency and prevent germ growth.
The facility failed to provide accurate and safe pharmaceutical services by not disposing of discontinued medications for two residents, not transcribing physician's orders for fentanyl patches into the MAR for a resident, and not checking blood pressure parameters before administering antihypertensive medication to another resident. These failures were confirmed through observations, interviews, and record reviews.
Missing Full-Time DON Oversight
Penalty
Summary
The facility failed to ensure that a Registered Nurse was designated to serve as the Director of Nursing on a full-time basis. The facility assessment dated 5/29/26 stated that a DON should be present full time five days per week, and it also identified two Registered Nurse Supervisors. A review of the DON's terminated W-2 dated 6/4/26 showed that the DON's last day of employment was 6/4/26, leaving the facility without a DON in place. During interviews, the Director of Staff Development stated that the DON quit on 6/4/26 and was responsible for overseeing the nursing department, and that not having a DON created a potential for residents' quality of care to be compromised. The Administrator stated that the DON was necessary to coordinate care between staff and residents and that there was a potential for a negative outcome when the facility did not have a DON. The facility policy titled Director of Nursing Services stated that the nursing services department is managed by the DNS, who is an RN employed full-time 40 hours per week, and that the DNS may serve as charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
Improper Storage of Cold Beverages and Opened Ice Cream
Penalty
Summary
The facility failed to store food in a safe and sanitary manner for 78 residents receiving oral diets. During an observation in the kitchen, meal trays were being set up with cups of apple juice, cranberry juice, and orange juice, and the temperature of the juices was 69.9 degrees Fahrenheit. During interviews, the cook stated the juices should have been between 37 and 40 degrees Fahrenheit and that 69 degrees Fahrenheit was too warm for juice. The Dietary Supervisor stated juice should be stored in the refrigerator or on ice prior to serving and kept at 40 degrees Fahrenheit or below. The facility policy for meal service stated cold foods are to be placed on trays as close to serving time as possible to keep temperatures below 41 degrees Fahrenheit, and cold beverages are to be pre-poured and kept refrigerated or frozen until needed. The facility also had an open box of ice cream stored in Freezer 1 with no use-by date labeled on it. The cook stated all kitchen staff were responsible for putting use-by dates on opened food stored in the freezer and that the ice cream should have a used-by date so staff would know it had not expired. The Dietary Supervisor stated that indicating the use-by date on ice cream was important so staff would know when it was expired and when not to use it. The facility policy for refrigerators and freezers stated that expiration dates on unopened food are observed and use-by dates are indicated once food is opened.
Infection Control PPE and Precaution Failures
Penalty
Summary
Infection control measures were not consistently followed for three residents on precautions. One resident was on Enhanced Barrier Precautions for a sacrococcyx pressure injury and chronic wounds, with orders for gown and gloves during care. During observation, an uncovered trash can in that resident’s room was overflowing with discarded PPE gowns. A CNA later stated she did not know PPE had to be disposed of in a closed container and had thrown it in the regular trash can after providing care. The ADON stated PPE must be disposed of in a closed container to contain germs and prevent cross contamination. A second resident was on contact isolation for active diarrhea and a history of C. diff. During observation, a CNA used alcohol-based hand rub, put on a gown, but did not don gloves before entering the room to answer the resident’s call light. After exiting, the CNA removed the gown and again used alcohol-based hand rub. The CNA stated she was unsure about gloves because she did not touch the resident and believed alcohol-based hand rub was sufficient for C. diff. The IP stated the CNA should have worn both gown and gloves and should have used soap and water for hand hygiene because alcohol-based hand rub does not kill C. diff germs. A third resident was on transmission-based precautions and had Enhanced Barrier Precautions for an indwelling catheter. During observation, a CNA entered the room and provided feeding assistance without wearing the required PPE. The CNA acknowledged the resident was on transmission-based precautions and stated she did not wear PPE. The IP and RNS stated staff entering a transmission-based precaution room and providing direct care are required to wear the appropriate PPE, including gown, gloves, and mask, and that PPE was available outside the room. The facility policy reviewed by surveyors stated staff are to use gowns and gloves for enhanced barrier precautions and to follow transmission-based precautions and infection control practices.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that Resident 21 had a call light within reach. Resident 21 was originally admitted and later readmitted to the facility with diagnoses including spinal stenosis, muscle weakness, dementia, and difficulty walking. A physician progress note dated 5/5/2025 stated that Resident 21 did not have the capacity to understand and make decisions. The care plan for alteration in physical functioning, revised 10/7/2025, directed that the call light be placed within easy reach and answered promptly. The MDS dated 3/26/2026 indicated Resident 21 required substantial to maximal assistance with toileting, showering, dressing, and transferring. During an observation on 6/22/2026 at 2:18 p.m., Resident 21 was resting quietly in bed and the call light was on the floor. CNA 10 entered the room to give Resident 21 tissues and left without placing the call light within reach. During interview, CNA 11 stated that when the call light was on the floor, staff were to ask the resident if they needed something to clip it onto the blanket, and stated Resident 21 could have a risk for falling if he tried to help himself because he could not reach the call light to summon help. The ADON stated that a call light not in reach would cause a delay of care, prevent the resident from calling for help, and could result in an emergency. The facility policy titled Answering the Call Light stated that the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Failure to Provide SNF ABN for Medicare Coverage Changes
Penalty
Summary
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for two sampled residents, Resident 86 and Resident 92, and therefore did not give written notice of Medicare coverage ending or potential financial liability for services not covered. During a concurrent interview and record review, the Business Office Manager stated that Resident 86’s last covered day for Medicare Part A was 4/16/2026 and Resident 92’s was 6/11/2026, and acknowledged that SNF ABNs were not provided in writing to either resident or their representatives. The Business Office Manager stated she was responsible for notifying residents or their representatives of changes in Medicare coverage and possible share of cost, and stated that failure to do so could leave them facing financial difficulties without being informed of changes in benefits or allowed to appeal those decisions. Resident 86’s record showed admission on 2/6/2026 with diagnoses including Alzheimer’s Disease, generalized muscle weakness, and abnormalities of gait and mobility. The MDS indicated the resident was unable to make decisions for self. During interview, Resident 86’s representative stated they were not given any written notification of changes in Medicare coverage and were receiving bills from the facility. The Administrator stated she was not clear on Advanced Beneficiary Notice policies and regulations and acknowledged that if residents were not told their Medicare coverage was ending, they may be unaware of their potential financial responsibilities and share of costs. The facility policy stated that when Medicare may not pay for otherwise covered skilled services, the resident or representative is to be notified in writing of why the services may not be covered and of potential liability for payment.
MDS Hearing Status and Hearing Aid Use Not Accurately Coded
Penalty
Summary
The facility failed to ensure that one sampled resident’s MDS assessment accurately documented hearing status and the use of hearing aids. Resident 92 was admitted with diagnoses including encephalopathy, dementia, anxiety, and generalized muscle weakness. The resident’s order summary indicated that ENT and Audiology consultation and treatment could be provided as needed. The MDS dated 5/22/2026 indicated the resident had minimal difficulty hearing and did not use a hearing aid or other hearing appliance. During a concurrent interview and record review, the MDS Nurse stated she had just learned that Resident 92 used hearing aids and acknowledged the MDS was not coded correctly. The MDS Nurse also stated the resident could have a decline in communication. The ADON stated that nursing staff were not aware the resident had or used hearing aids.
Failure to Initiate and Implement Hearing Loss Care Plan
Penalty
Summary
The facility failed to ensure that one sampled resident, Resident 92, had a care plan initiated and implemented for hearing loss. The resident was admitted with diagnoses including encephalopathy, dementia, anxiety, and generalized muscle weakness. The admission record also showed an order for ENT and audiology consultation and treatment as needed. In the Minimum Data Set dated 5/22/2025, Resident 92 was documented as having adequate hearing, not using a hearing aid or other hearing appliance, and sometimes being able to express wants and ideas and understand others. The resident was dependent on nursing staff for toileting, showering, dressing, sitting, and standing. During interviews, LVN 4 stated that all licensed nursing staff are responsible for initiating and implementing nursing care plans and that Resident 92 should have a care plan for hearing aids and hearing loss. The ADON stated that any licensed nurse can initiate a care plan for hearing and should be updating the care plans or continuity of care. The facility policy titled Care Plans Comprehensive Person-Centered stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident to meet physical, psychosocial, and functional needs.
Failure to Provide Access to Hearing Aids
Penalty
Summary
The facility failed to provide one sampled resident with access to her hearing aids, which were stored in the Social Service Director’s file cabinet. Resident 92 had diagnoses including encephalopathy, dementia, anxiety, and generalized muscle weakness. Her record showed an order for ENT and audiology consultation and treatment as needed, and the MDS indicated she had adequate hearing, did not use hearing aids, and was sometimes able to express wants and understand others. During interview, the resident stated she could not hear when spoken to and said it would be great to be seen by a hearing doctor. Staff interviews confirmed the hearing problem and the lack of hearing aid use. A CNA stated the resident had problems with hearing, often asked staff to repeat words, and did not use hearing aids. The SSD stated the resident had hearing aids stored in the SSD’s file cabinet, but the SSD did not know how to turn them on and was not sure if they were working; the SSD also stated they were supposed to be checked by an ENT doctor and that the resident would not be able to express her needs and wants or communicate if not provided with the hearing aids. The ADON stated no staff in the facility was aware the resident had hearing aids. ENT documentation showed diminished hearing and hearing loss in the left ear, and the resident belonging list identified two hearing aids. The facility’s policy for hearing aid care required documentation of checks and battery replacement, but the report did not show that the resident’s hearing aids were being provided or used.
Failure to Complete Nursing Competency Upon Hire
Penalty
Summary
The facility failed to ensure that a skills competency was completed upon hire for the Assistant Director of Nurses (ADON). During a concurrent interview and record review, the Director of Staff Development stated that nurse competencies are completed upon hire and annually thereafter, but the ADON, who was hired on 12/1/25, did not have competencies completed when she was hired. The Director of Staff Development stated that competencies are used to ensure staff are knowledgeable and competent in the job they were hired to do. During an interview, the ADON stated that skills competencies are done upon hire and annually thereafter, but she had not had any skills competencies completed since being hired. The Administrator stated that skills competencies are done upon hire and annually to ensure staff are competent in the care they provide to residents. Review of the facility policy titled Competency of Nursing Staff, dated 3/2025, showed that all nursing staff must meet specific competency requirements and that facility and resident-specific competency evaluations will be conducted upon hire, annually, and as deemed necessary based on the facility assessment.
Unnecessary Lorazepam Use Without Required Behavior Monitoring
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs related to lorazepam use. For one resident, physician orders dated 5/22/26 and 6/9/26 directed lorazepam every 12 hours as needed for anxiety, and a 5/30/26 order required monitoring of anxiety episodes every shift for lorazepam use. Review of the June 2026 MAR showed multiple lorazepam administrations with no documented anxiety episodes before each dose, including doses given on 6/1, 6/2, 6/3, 6/9, 6/12, 6/13, 6/14, 6/19, and 6/22. During interview, an LVN stated the medication was being given because the resident would request it daily and would repeatedly approach staff at the permissible frequency without indication, monitoring, or documentation of anxiety behaviors. The ADON stated the medication was prescribed as needed for anxiety and restlessness, but it was administered regularly without behavior monitoring or documentation. The facility policy on unnecessary drugs stated adequate indications for use require documented clinical rationale based on assessment and therapeutic goals after safer treatments are deemed clinically contraindicated. For the second resident, the admission record listed diagnoses including malignant neoplasm of colon, anxiety disorder, atrial fibrillation, and pneumonia, and the MDS showed moderately impaired cognitive skills and dependence on staff for bathing and toileting hygiene. A physician order for lorazepam 0.5 mg by mouth at bedtime for sleep was documented as a telephone order without a time. The ADON and QA stated there was no documentation monitoring the resident’s behavior related to inability to sleep or specific anxiety behaviors for the use of lorazepam, and the facility policy stated that indications for initiating a medication are determined by evaluating the resident’s physical, behavioral, mental, and psychosocial signs and symptoms with documentation and evaluation in the medical record.
Medication Error Rate Exceeded 5% During Medication Pass
Penalty
Summary
A medication error rate of 10.34% was identified during a medication administration pass when one licensed nurse failed to administer three prescribed medications to a resident: Rena Vite, vitamin C, and zinc sulfate. The observation on 6/23/26 at 8:45 a.m. showed LVN 3 administering the resident’s 9:00 a.m. medications but not giving those three ordered supplements during the pass, resulting in three medication errors out of 29 medication opportunities. The resident had intact cognition, partial to moderate assistance needs, and a stage 3 reopened sacrococcyx pressure injury. The resident’s H&P stated the resident had capacity to understand and make decisions, and the admission record listed diagnoses including anemia, type 2 diabetes, and hypertension. The order summary showed the resident was prescribed Rena Vite twice daily, vitamin C 500 mg twice daily, and zinc sulfate 220 mg daily, and the care plan stated the resident was at risk for infection and would receive wound supplements to promote healing for the stage 3 sacrococcyx pressure injury. LVN 3 stated she missed giving the resident the Rena Vite, vitamin C, and zinc sulfate and was not sure what happened.
Failure to Follow Up on Recommended Dental Services
Penalty
Summary
The facility failed to follow up on necessary dental services for one resident who was admitted with cardiomegaly, enthesopathy, HTN, and CHF. The resident’s MDS dated 4/8/2026 indicated moderately impaired cognitive skills and a need for supervision or touching assistance with oral hygiene. Social Services documentation dated 5/15/2026 stated the dentist recommended teeth cleaning and the family agreed to pay $200 out-of-pocket for the cleaning. A dental progress note dated 5/29/2026 documented a recommendation for full mouth x-rays when eligible, and a dental care note dated 6/23/2026 documented heavy tartar with recommendations for scaling, root planing, and x-rays; the resident had no dental insurance coverage and was self-paying. During a concurrent observation and interview on 6/24/2026, the resident stated there was something stuck in his teeth that he could not get out, and his mouth was observed to have crowded and overlapping teeth. The resident stated he had told staff about his concern regarding his teeth. During interview and record review on 6/25/2026, the SSD stated the family had agreed to cover the out-of-pocket cost for dental cleaning, the resident had no dental insurance, and the facility covered dental expenses if a resident needed dental services, but she did not follow up on the resident’s dental service. The SSD stated it was her responsibility to take care of residents’ dental needs. QA stated that if the resident’s dental needs and dentist recommendations were not followed up on, the resident was at risk for pain and his food intake would be negatively affected leading to weight loss.
Arbitration Agreement Not Clearly Explained to Resident Representative
Penalty
Summary
The facility failed to ensure the terms and conditions of a binding arbitration agreement were clearly explained to the resident or the resident representative for one sampled resident. Resident 90 was initially admitted on 9/2/2024 and later readmitted with diagnoses including Parkinson's disease, unspecified dementia, anxiety disorder, and diabetes mellitus. The resident's MDS dated 6/12/2026 indicated moderately impaired cognitive skills, and a physician progress note dated 5/13/2026 stated the resident could make needs known but could not make medical decisions; the note identified FM1 as the responsible party. During interviews, FM1 stated he never signed an arbitration agreement for Resident 90 and had never been told about it, despite stating he was responsible for signing all forms and consents for the resident. The admission coordinator stated FM1 signed the arbitration agreement on 3/20/2026 and acknowledged she could not remember whether she had spoken directly with FM1 about the form. The coordinator stated the arbitration form should be explained to the resident or representative before signing, and the QA nurse stated the purpose and context of the agreement should be discussed so the resident or representative understands the terms and effect of signing. The facility policy stated the agreement would be explained in a manner and language the resident and representative understand, and that if the resident lacked decision-making capacity, the resident representative would decide whether to sign or decline.
Missing Annual Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Aides (CNAs) received the mandatory five-hour annual dementia management training. During a concurrent interview and record review with the Director of Staff Development, CNA trainings and the annual 2026 mandatory in-service calendar were reviewed, and the DSD stated that staff are to be provided with five hours of dementia training annually. The DSD stated that only one hour of dementia training had been provided within the last year and that dementia training was important to ensure staff are equipped with the knowledge and skills needed to care for residents with cognitive concerns. During interviews, the Assistant Director of Nursing and the Administrator both stated that dementia training was mandatory and that all staff must complete five hours annually. The ADON stated dementia residents were at risk to be mistreated and neglected when staff are not educated on how to provide care. Review of the facility policy titled Facility Inservice Education Program indicated that each employee will have an educational profile completed at hire and annually, the Staff Development Department will maintain records of in-services attended, and dementia-specific caregiver training is required at five hours per year for CNAs.
Failure to Document and Track Resident Council Concerns on Required Response Form
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy for documenting and tracking concerns raised during resident council meetings. Review of resident council minutes from two meetings showed that residents reported problems with timely toileting assistance, specifically requesting that nurses regularly check on residents who use the restroom often at least every two hours, and concerns that call lights were not being answered in a timely manner. These concerns were recorded in the council minutes but were not transferred to or documented on the facility’s Resident Council Response Form, which is the tool designated by policy to formally record issues and track their resolution. The Activities Director, who had been in the role for about a month, reported being unaware of prior resident council concerns and stated that council minutes should be shared with department heads so they can investigate and address issues. The DON acknowledged that the facility was aware of the residents’ concerns about delayed call light response and the need for assistance with toileting and hygiene at least every two hours, and stated that staff in-services were provided. However, the DON confirmed that the Resident Council Response Form was not used as required by the facility’s Resident Council policy. The policy specifies that the Response Form will be used to track issues and their resolution, that the responsible department will address the concerns, and that the QAPI committee will review resident council information as part of its quality review. Because the form was not used, the issues raised in the two council meetings were not formally tracked or integrated into the QAPI review process.
Failure to Reassess and Notify Physician for Low Blood Pressure and Wound Infection
Penalty
Summary
The facility failed to provide necessary care and services for a resident with multiple complex medical conditions, including end stage renal disease, diabetes with a foot ulcer, dependence on dialysis, peripheral vascular disease, and acute osteomyelitis. On the morning of the incident, the resident was found to have a low blood pressure reading of 90/42 mmHg. The assigned nurse administered midodrine as ordered but did not reassess the resident's vital signs after administration or prior to sending the resident to dialysis. The nurse also did not notify the physician of the low blood pressure, despite being aware that dialysis can further lower blood pressure and that the resident was at risk for clinical instability. The RN Supervisor was informed of the low blood pressure and administration of midodrine but also did not reassess the resident or notify the physician. The resident was subsequently transferred to the hospital from the dialysis center due to hypotension. Additionally, the facility failed to notify the physician when a foul-smelling odor was observed from the resident's right Achilles wound during wound care treatment the previous day. The wound had worsened, with increased swelling, maceration, and slough tissue, and the presence of a foul odor, which may indicate infection. The treatment nurse did not document a change in condition or notify the physician to obtain updated treatment orders. The wound care consultant, who assessed the resident the following day, noted signs of infection and significant pain but was not informed by staff of the foul odor observed earlier. Interviews with facility staff, including the DON, confirmed that the nurses were responsible for ensuring residents were stable before being sent to dialysis and for notifying the physician of significant changes in condition, such as low blood pressure or signs of wound infection. The facility's policies and job descriptions also required prompt notification and documentation of changes in condition. The failures to reassess the resident, notify the physician, and document changes in condition had the potential to delay necessary care and treatment.
Failure to Supervise Residents and Secure Smoking Patio Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision to prevent accidents for two residents who were left unsupervised on the smoking patio after the last scheduled smoking time. Both residents had documented needs for supervision while smoking, as indicated by their Smoking Safety Screens and care plans. Despite these requirements, staff did not supervise the residents on the patio at approximately 7:00 p.m., and the door to the smoking patio was not secured after the designated smoking period ended at 6:00 p.m. One resident, who had diagnoses including anxiety disorder, repeated falls, major depressive disorder, and a recent fracture, was assessed as having intact cognition but required substantial assistance with activities of daily living and was only permitted to smoke with supervision and a protective apron. The other resident had severe cognitive impairment and also required supervision while smoking. On the evening in question, the two residents remained on the patio unsupervised, during which time one resident became verbally aggressive and threw a plastic coffee mug at the other, resulting in a bump on the head and escalating pain over the following days. Interviews with staff revealed that CNAs and LVNs were unaware of the residents' whereabouts and did not monitor or redirect them as required. Staff acknowledged that residents sometimes remained on the patio unsupervised after smoking times, and that the patio door was not consistently locked. The facility's policy required supervision and securing of the patio after smoking times, but these procedures were not followed, directly leading to the incident of resident-to-resident aggression and injury.
Failure to Report COVID-19 Outbreak to CDPH
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the California Department of Public Health (CDPH) after three residents tested positive for COVID-19 on the same day. Resident 6, who had arthrogryposis multiplex congenita and required substantial assistance with activities of daily living (ADLs), tested positive for COVID-19. Resident 7, with a diagnosis of diabetes mellitus and moderate cognitive impairment, also tested positive, as did Resident 8, who had similar diagnoses and care needs. The positive test results for all three residents were documented on the same date, indicating an outbreak within the facility. Despite the facility's policy requiring the reporting of communicable disease outbreaks to appropriate agencies, including CDPH, the Infection Prevention Nurse reported the outbreak only to the local health department and not to CDPH. This omission was confirmed during interviews with both the Infection Prevention Nurse and the Director of Nursing, who acknowledged that such outbreaks should be reported to CDPH to ensure proper measures are taken. The facility's policy, dated December 2007, specifically mandates reporting of unusual occurrences, including communicable disease outbreaks, as required by federal or state regulations.
Failure to Provide Adequate Pain Management During Wound Care
Penalty
Summary
A resident with a Stage 4 pressure ulcer to the left buttock, who was nonverbal and dependent on staff for all activities of daily living, experienced unrelieved and uncontrolled pain during wound care and repositioning. The resident had a history of anoxic brain injury and functional quadriplegia, rendering her unable to express needs or communicate verbally. Staff observed and reported that the resident exhibited facial grimacing and moaning—recognized nonverbal indicators of pain—during pressure ulcer treatments and repositioning. Despite these clear signs of pain, the treatment nurse continued with wound care procedures without stopping to assess or address the resident's discomfort. The facility failed to ensure that pain management protocols were followed as ordered by the physician and outlined in the resident's care plan. Specifically, Tylenol 500 mg was not administered one hour prior to wound treatment as required, and wound care was not consistently performed within one hour after pain medication administration. Multiple instances were documented where the timing of pain medication and wound care did not align, resulting in the resident undergoing painful procedures without adequate pain relief. Additionally, nurses did not verify whether pain medication had been given before starting wound care, and staff did not consistently assess or document the resident's pain before, during, and after treatment. Interviews with nursing staff and review of records confirmed that the facility's pain assessment and management policy was not followed. Staff acknowledged that they recognized the resident's nonverbal cues as indicators of pain but failed to intervene appropriately, such as stopping treatment, reassessing pain, or notifying the physician. The care plan specifically stated that the resident should not experience pain or facial grimacing during care, yet these interventions were not implemented. The deficiency resulted in the resident experiencing unnecessary pain and suffering during routine wound care and repositioning.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication administration for several residents, as evidenced by multiple deficiencies observed during survey. One resident with a history of hypertension, osteoarthritis, and glaucoma did not receive metoprolol succinate ER within 60 minutes of the scheduled time on multiple occasions, contrary to facility policy. Additionally, this resident had duplicate orders for diclofenac (Voltaren) topical gel that were not clarified or discontinued, and there was inaccurate documentation of medication administration, including instances where medications were documented as given when they were not administered. The same resident was found to have eye drops at bedside despite being assessed as unable to self-administer, and some prescribed eye medications were unavailable or not administered as ordered. Another resident with severe cognitive impairment was prepared to receive vitamin B complex instead of the ordered thiamin (vitamin B-1), and the error was only identified after the medication was refused. The facility staff prepared the incorrect medication, and there was no physician order for vitamin B complex. In a separate incident, a resident with diabetes and neuropathy received Ciprodex otic suspension incorrectly, as the nurse did not shake the suspension before administration and instilled the drops with a five-minute interval between each drop, causing discomfort and deviating from professional standards and facility policy, which required all drops to be instilled at once followed by a five-minute wait. Controlled medication documentation was also found to be inaccurate for two residents. For one resident, the count of pregabalin capsules did not match the controlled drug record (CDR) or the electronic medication administration record (eMAR), as the nurse failed to document administration in the CDR immediately after giving the medication. Similarly, for another resident prescribed lacosamide for seizures, the medication count and documentation were inconsistent, with the nurse admitting to forgetting to document on the controlled count sheet. These documentation lapses were confirmed by the DON, who acknowledged the importance of accurate and timely documentation for controlled substances.
Medication Administration Errors Exceeding Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration, resulting in an error rate of 18.75%. For one resident with diagnoses including hypertension, osteoarthritis, and glaucoma, a nurse administered metoprolol succinate ER more than 60 minutes after its scheduled time on multiple occasions, contrary to facility policy. Additionally, the same resident did not receive prescribed ophthalmic medications (timolol, Alphagan P, dorzolamide, and artificial tears) as ordered. The nurse documented these medications as administered, but later admitted the resident self-administered them, despite an assessment indicating the resident was unable to self-administer medications. The medications were found at the resident's bedside, and the nurse did not have all required eye drops in stock at the time of administration. Another resident with severe cognitive impairment and multiple diagnoses was prepared to receive vitamin B complex by a nurse, although the physician's order specified thiamin (vitamin B-1) only. The nurse realized the error after preparing the medication and acknowledged that administering vitamin B complex instead of thiamin would not be in accordance with the physician's order. The resident refused all medications except one, so the incorrect medication was not administered, but the preparation of the wrong medication was still identified as a deficiency. Facility policy required medications to be administered as prescribed and within 60 minutes of the scheduled time, and only by staff authorized to do so. The policy also specified that residents assessed as unable to self-administer medications should have all medications administered by nursing staff, and unauthorized medications found at bedside should be removed. These policies were not followed in the cases described, leading to the cited deficiencies.
Medication Storage, Labeling, and Removal Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and management of medications and biologicals. In one instance, a nurse administered insulin glargine to a resident using a pen whose pharmacy label did not match the current physician order in the electronic medical record. The nurse also failed to label the insulin pen with the date it was opened, contrary to manufacturer specifications and facility policy. The Director of Nursing confirmed that the discrepancy between the pharmacy label and the physician order posed a risk for medication errors, and that the open date was necessary to determine the insulin's expiration and potency. Another deficiency was observed when a discontinued vial of insulin lispro for a resident was found in the medication room refrigerator. The Registered Nurse Supervisor acknowledged that the medication should have been removed after discontinuation to prevent accidental administration. Review of the resident's records confirmed that the insulin had been discontinued and replaced with an oral medication, but the vial remained accessible in the refrigerator. Additional issues included the discovery of multiple eye drop medications at a resident's bedside, despite documentation that the resident was not assessed as capable of self-administering medications. The nurse present removed the medications, recognizing the risk of incorrect administration. Furthermore, expired naloxone nasal spray containers were found in a medication cart, and staff confirmed these should have been discarded as they would not be safe or effective for use. Facility policies reviewed by surveyors required proper labeling, timely removal of discontinued or expired medications, and assessment of residents' ability to self-administer medications, all of which were not followed in these instances.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to ensure that three sampled residents received food that was appetizing, palatable, and served at a safe and appealing temperature. Resident 82, who had diagnoses including diabetes mellitus, hypertension, and hyperlipidemia, was noted to have variable food intake possibly due to intolerance to the prescribed diet. His wife brought in outside food because he did not like the meals provided. Resident 48, with dysphagia, diabetes mellitus, and hyperlipidemia, and Resident 41, with diabetes mellitus, chronic kidney disease, and spinal stenosis, also expressed dissatisfaction with the food, describing it as awful, tasteless, and cold. Resident 41 reported keeping her own salt and pepper at bedside and described the breakfast as repetitive and the eggs as inedible and cold. During an observation and interview, a test tray consisting of pork, carrots, and polenta was found to be unseasoned, greasy, tasteless, and not visually appealing. The carrots appeared pale and grayish, and the polenta lacked flavor. The cook confirmed that food was prepared offsite and delivered in hot carts, with her responsibility limited to checking the food before distribution. The facility's policy required the dietary service supervisor to ensure residents received proper food items at appropriate temperatures for safety and palatability, but this standard was not met for the sampled residents.
Failure to Implement Corrective Actions for Systemic Quality Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to implement corrective actions for several identified systemic problems. These deficiencies included the lack of systems to ensure timely response to call lights, proper implementation of activities of daily living, accurate pharmaceutical services and procedures, prevention of significant medication errors, correct storage and labeling of biologicals and medications, sanitary food storage, and maintenance of clinical records according to professional standards. The report notes that these failures had the potential to result in residents not receiving necessary services and care. Interviews with the Administrator and Director of Nursing (DON) confirmed ongoing issues in areas such as pressure ulcers, medication management, and call light response. The DON acknowledged that all staff are responsible for identifying skin issues and answering call lights, and recognized the need for improvement in the deficient practices identified. Review of the facility's QAPI policy indicated objectives for monitoring and correcting negative indicators, but the report documents that these objectives were not met in practice.
Inaccurate MDS Coding of Continence Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's continence status. Specifically, the MDS for one resident was incorrectly coded to indicate incontinence, despite multiple sources confirming the resident was continent. The resident's admission record listed several diagnoses, including diabetes mellitus, myocardial infarction, a broken left arm, and hypertension. Interdisciplinary team meeting notes and the MDS itself documented that the resident was able to make decisions and communicate needs. Interviews with both a CNA and an LVN confirmed the resident was not incontinent and did not require assistance with toileting, instead using a urinal independently. Further interviews revealed that the MDS nurse, responsible for completing the MDS assessments, had relied on information from the initial care plan meeting and family input. However, during a joint interview with the resident and the MDS nurse, the resident stated he was not incontinent and only used diapers at night due to delayed assistance, not due to actual incontinence. The facility's policy required staff to assess and document continence status accurately, referencing MDS criteria. The inaccurate coding on the MDS was identified as a discrepancy that could affect the resident's care.
Failure to Update Care Plan for Resident's Toe Infection
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's toe infection. The resident, who had a history of hypertension and diabetes mellitus and was admitted with severely impaired cognition, was identified as having left second toe cellulitis, for which an antibiotic was ordered. Despite the identification of the infection and the initiation of treatment, the care plan was not updated or revised to reflect the new condition. Interviews with facility staff, including the Infection Prevention Nurse, an LVN, and the Director of Nursing, confirmed that the care plan should have been implemented or revised at the time the infection was identified. The facility's policy also indicated that care plan goals and objectives should be reviewed and revised when there is a significant change in a resident's condition. However, no care plan addressing the toe infection was created or updated, resulting in a lack of documented interventions and monitoring for the resident's new infection.
Improper Administration of Otic Medication
Penalty
Summary
The facility failed to ensure that a resident's Ciprodex otic (ciprofloxacin and dexamethasone) ear drops were administered according to professional standards of practice and the facility's own policy. During a medication pass, an LVN did not shake the ear suspension prior to administration and instilled one drop at a time into the resident's right ear, waiting five minutes between each drop, resulting in a total administration time of 20 minutes. The resident, who had moderately impaired cognition and required significant assistance with activities of daily living, complained of neck pain during the process due to prolonged tilting of the head. The facility's policy specified that the prescribed number of drops should be instilled into the ear canal, followed by instructing the resident to remain in the same position for approximately five minutes. The LVN, however, was following incorrect instructions received during an in-service, which led to the deviation from policy. The DON confirmed that the medication should have been administered as four drops at once, not with intervals, and acknowledged that the resident could experience discomfort and potentially refuse future doses as a result of the improper administration.
Failure to Follow Physician Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered for a resident with a Stage 4 pressure ulcer on the left buttock. The resident, who was dependent on staff for all activities of daily living due to anoxic brain injury and functional quadriplegia, had physician orders specifying that the wound should be cleansed with normal saline, Medi Honey applied to the wound bed, and barrier cream to the peri-wound area daily. However, during an observation, the treatment nurse was seen applying Santyl ointment instead of Medi Honey as ordered. The nurse admitted to using Santyl based on previous experience rather than current physician orders and acknowledged that the correct treatment should have been verified prior to administration. Record reviews confirmed that the physician's orders and the treatment administration record both specified Medi Honey for the wound care regimen. The facility's policy required staff to verify the five rights of medication administration before providing care, which was not followed in this instance. Interviews with the treatment nurse and the Director of Nursing confirmed that the deviation from the prescribed treatment could directly impact the resident's well-being and healing process. The deficiency was identified through observation, interview, and record review, and was limited to this resident.
Failure to Administer Medication Within Required Timeframe
Penalty
Summary
A deficiency occurred when a resident with a history of hypertension, osteoarthritis, pain syndrome, retinal edema, and glaucoma did not receive their prescribed metoprolol succinate ER 25 mg within the facility's required timeframe. The medication, ordered to be administered twice daily with meals and held for low systolic blood pressure or pulse, was scheduled for 7:15 a.m. but was not given until 9:00 a.m. on the observed date. Facility policy requires medications to be administered within 60 minutes of the scheduled time, and this late administration was confirmed by both the RN Supervisor and the Director of Nursing. Review of the resident's medication administration history revealed that this medication was administered late on ten occasions within a two-week period. The late administration was observed directly by surveyors and confirmed through interviews and record reviews. The facility's policy on medication administration, which mandates adherence to prescriber orders and a 60-minute window for administration, was not followed in these instances.
Failure to Honor Resident's Cultural Food Preferences
Penalty
Summary
The facility failed to ensure that a resident's food preferences, including cultural preferences, were identified and honored. The resident, who was admitted with diagnoses including Parkinson's disease, muscle weakness, and dementia, had a severe cognitive impairment and was unable to express his preferences verbally. The resident primarily spoke Japanese and had limited English proficiency, and no staff at the facility spoke Japanese. Despite this, the dietary staff supervisor only interviewed the resident, who was unable to communicate effectively, and did not consult the resident's family or representative to determine food likes, dislikes, or cultural preferences. The care plan indicated a goal to include the resident's food preferences in his therapeutic diet, but this was not achieved. Interviews with staff confirmed that the resident never received Japanese food and that the dietary staff supervisor was unaware of the resident's language or cultural background. The supervisor acknowledged that, given the resident's severe cognitive impairment, the family should have been interviewed to obtain this information. The facility's policy required the dietary service supervisor to participate in food preference updates and resident visits, but these steps were not followed. As a result, the resident did not receive food items consistent with his cultural preferences and choices.
Falsification of Medication Administration Records for Ophthalmic Medications
Penalty
Summary
Licensed staff failed to accurately document medication administration for a resident with multiple diagnoses, including glaucoma, hypertension, and pain syndrome. The resident had physician orders for several ophthalmic solutions and artificial tears to be administered at specific times daily. During medication administration observation, the nurse prepared and administered oral medications but did not include any of the prescribed eye drops. Despite this, the Medication Administration Record (MAR) reflected that the eye drops were administered at the scheduled times. Further review revealed that the resident was assessed as unable to self-administer medications, with a physician order specifying that all medications were to be given by a licensed nurse. The nurse initially claimed to have administered the eye drops, then stated the resident self-administered them, and finally acknowledged that the medications were not administered and that documentation indicating otherwise was incorrect. The nurse also admitted that some of the prescribed eye drops were not available in the medication cart and would need to be reordered from the pharmacy. The Director of Nursing confirmed that the facility had not reassessed the resident for self-administration and that nurses were not permitted to document medications as given when they were not administered. Facility policy required that only the individual who administers the medication should document it on the MAR immediately after administration, and that unadministered doses should be documented as such. The failure to follow these procedures resulted in inaccurate medical records for the resident.
Failure to Perform Hand Hygiene Between Resident Care
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to perform hand hygiene between providing care to residents and when entering and exiting a resident room, as observed by surveyors. During interviews, the LVN acknowledged the lapse in hand hygiene, and the Director of Nursing (DON) confirmed that hand hygiene is the primary method to prevent the spread of infection and is required between resident care and when moving in and out of resident rooms. Review of the facility's hand hygiene policy indicated that all personnel are required to follow handwashing procedures to prevent the spread of infections to staff, residents, and visitors.
Failure to Follow Antibiotic Stewardship Protocol Prior to Prescribing Antibiotics
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship protocol for one of three sampled residents by prescribing an antibiotic without meeting established criteria. Specifically, a resident with a history of hypertension and diabetes mellitus, who was admitted with severe cognitive impairment and required supervision for daily activities, was prescribed Doxycycline for left toe cellulitis. The order for the antibiotic was placed without first obtaining a wound culture or confirming that the resident met McGreer's Criteria for infection, as required by facility policy. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that a wound culture should have been collected prior to starting the antibiotic to ensure appropriate treatment and adherence to the facility's protocol. The facility's policy states that antibiotics should only be prescribed when clinical criteria for infection are met and pathogen susceptibility is determined. The failure to follow these procedures was confirmed through record review and staff interviews.
Failure to Maintain Home-Like Environment Due to Damaged Screen Door
Penalty
Summary
A deficiency was identified when a resident was not provided with a home-like environment, as evidenced by a large hole in the sliding screen door of the resident's room. The resident, who was admitted with diagnoses including diabetes mellitus, hypertension, and hyperlipidemia, reported that the hole had been present since admission and had remained unaddressed for approximately four months. The resident was able to communicate and expressed awareness of the issue during an interview. Staff interviews revealed that a CNA noticed the hole but had not reported it, and the maintenance supervisor confirmed that monthly room checks were conducted, but could not provide documentation of repairs for the resident's room prior to the recent replacement of the screen door. The facility's policy required a safe, clean, and comfortable environment, but this was not maintained for the resident, as the hole in the screen door persisted for an extended period.
Failure to Maintain Safe Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe room temperature for a resident, which is a violation of the resident's right to a homelike environment. The resident, who was cognitively intact and required substantial assistance with personal hygiene, toileting, and transferring, reported that their room temperature was excessively hot, reaching 90 degrees Fahrenheit. This discomfort was confirmed by a family member who checked the room temperature. The facility's policy requires room temperatures to be maintained between 71 and 81 degrees Fahrenheit, but this standard was not met. Interviews with facility staff revealed that room temperatures were only checked upon receiving complaints, rather than being monitored daily as required by the facility's policy. The Maintenance Supervisor acknowledged that room temperatures should be logged daily to ensure compliance, especially for residents unable to communicate their discomfort. The Administrator also recognized the importance of daily monitoring to prevent risks such as dehydration and temperature-related health issues. Despite these acknowledgments, the facility's practice did not align with its policies, leading to the deficiency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of aggressive behavior, slapped and punched him repeatedly. The incident occurred after the aggressive resident expressed a preference for not having roommates and a dislike for noise, yet was not provided a private room or transferred to a higher level of care. The aggressive resident had severe cognitive impairment and a history of mood fluctuations, which were documented in his care plan but not adequately addressed. The aggressive resident's care plan included goals to interact peacefully and prevent behavioral episodes, but the facility did not develop a plan of care that considered his need for a private room. Staff interviews revealed that the aggressive resident was known to become suddenly angry and had previously been involved in altercations. Despite this, the facility did not take appropriate measures to prevent the incident, such as providing a private room or closer monitoring. The incident resulted in the victim sustaining facial redness and pain, as well as emotional and psychological distress. The facility's policy on identifying types of abuse and monitoring resident interactions was not followed, contributing to the failure to prevent the altercation. Interviews with staff indicated that the incident could have been avoided with better planning and monitoring of the aggressive resident's behavior.
Failure to Implement Care Plan for Resident with Wandering Behavior
Penalty
Summary
The facility failed to implement the care plan interventions for a resident with wandering behavior, which resulted in the resident entering her previous room after an alleged physical altercation with her former roommate. The resident, who has dementia and major depressive disorder, was admitted to the facility with a history of repeated falls and required moderate assistance for mobility. Despite the care plan indicating the need for constant visual checks and hourly monitoring of the resident's whereabouts, staff did not document these checks, leading to the resident's unsupervised entry into her previous room. Observations and interviews revealed that the resident was seen wheeling herself around the activity room and into the hallway without staff assistance. A Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN) acknowledged the need for regular monitoring due to the resident's involvement in a recent altercation, but admitted that documentation of hourly rounding was not maintained. The Social Service Director (SSD) and the facility Administrator confirmed the importance of monitoring the resident to prevent further incidents and ensure safety, as outlined in the care plan. The care plan, revised after the altercation, emphasized the need to maintain a safe distance from other residents and to separate the resident from the alleged victim. However, surveillance footage confirmed that the resident entered her previous room, indicating a lapse in the implementation of the care plan. The facility's policies on care plans and resident-to-resident altercations stress the importance of documenting interventions and their effectiveness, which was not adhered to in this case.
Failure to Timely Provide Medical Records
Penalty
Summary
The facility failed to provide a copy of medical records upon written request from an authorized legal representative for a resident within the required timeframe. The resident, who was admitted with severe sepsis, septic shock, and vascular dementia, had severe cognitive impairment as indicated by the Minimum Data Set. The legal representative submitted a request for the resident's medical records on 8/14/2024, but the facility did not provide the records until 9/24/2024, which was beyond the facility's policy of providing records within 48 hours of the request. The delay in providing the requested medical records was attributed to the facility's process of routing requests from law offices through their legal team, as stated by the Administrator. The facility's policy, revised in 9/2024, required that medical records be released within 48 hours of the request, excluding weekends and holidays. However, the facility did not adhere to this policy, resulting in a violation of the resident and the legal representative's rights to access the medical records in a timely manner.
Failure to Timely Provide Medical Records
Penalty
Summary
The facility failed to provide a copy of medical records upon written request from an authorized legal representative for a resident within the required two working days as per the facility's policy. The resident, who was admitted with severe sepsis, septic shock, acute pyelonephritis, and Alzheimer's disease, had severely impaired cognition. The legal representative submitted a request for the resident's complete medical record via fax, which was received by the facility on August 30, 2024. The Medical Records Director acknowledged the request and stated that the facility's process allowed 15 calendar days to submit records for discharged residents, but only two days for in-house residents. Despite this, the records were not submitted until September 6, 2024, via email, which exceeded the two-day requirement. The Administrator also incorrectly stated that the facility had 15 days to submit the records, misunderstanding the policy for in-house residents. This resulted in a violation of the resident and legal representative's rights to timely access the medical records.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident at high risk for skin breakdown. The resident, who had a history of diabetes mellitus type 2, hemiplegia, and was bed-confined, was admitted with existing pressure ulcers that were not properly measured upon admission. The facility's policy required wound measurements to be documented within eight hours of admission, but this was not done until several weeks later, leading to a lack of baseline data to monitor the progression of the wounds. Observations revealed that the resident developed new pressure ulcers and existing ones worsened under the facility's care. A stage 1 pressure ulcer on the sacrococcyx developed into a stage 2 ulcer, and a new diabetic wound appeared on the left malleolus. The facility did not implement timely interventions such as providing a low air mattress, which was only ordered months after admission, despite the resident's high risk for pressure sores as indicated by the Braden Scale. Interviews with nursing staff confirmed that the facility did not adhere to its own policies regarding wound assessment and intervention. The admitting nurse failed to measure the resident's wounds upon admission, and the treatment nurse did not ensure the resident had an air mattress until much later. The facility's policy emphasized the importance of evaluating the resident's condition, implementing appropriate interventions, and monitoring their effectiveness, all of which were not adequately followed, leading to the deterioration of the resident's skin condition.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to include a resident's representative in the care planning process, which resulted in a deficiency. The resident, who was admitted with diagnoses of malignant neoplasm of the bone and congestive heart failure, experienced a change in condition during a transfer to an infusion appointment. The resident had shortness of breath and a low blood oxygen level, requiring a breathing treatment that delayed the appointment. However, there was no documentation indicating that the resident's representative was informed of this change in condition or the delay. Interviews with facility staff, including the Minimum Data Set Nurse and the Registered Nurse Supervisor, confirmed that the resident's representative should have been notified of the change in condition and involved in the decision-making process. The facility's policy on resident rights, revised in February 2021, also supports the requirement for resident representatives to be informed and participate in care planning and treatment. The lack of communication with the resident's representative was identified as a violation of the resident's rights.
Failure in Pain Management Documentation and Assessment
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 1, who was admitted with a diagnosis of malignant neoplasm of the bone and articular cartilage. The resident was prescribed Norco for moderate pain, but the administration of seven doses from September 1 to September 3 was not documented on the Medication Administration Record (MAR). Additionally, the facility did not assess and document the resident's pain using the pain rating scale, nor did they evaluate and document the effectiveness of the pain medication as per the facility's policy. The Controlled Medication Count Sheet indicated that Norco was administered to the resident on specific dates and times, yet these administrations were not recorded in the MAR. Nursing progress notes on September 2 and September 3 documented the administration of Norco for severe pain, but the effectiveness of the medication was noted at the same time as its administration, which is inconsistent with proper assessment procedures. The Minimum Data Set Nurse (MDSN) confirmed the lack of documentation and the failure to reassess the resident's pain after medication administration. Interviews with facility staff, including the Registered Nurse Supervisor, revealed that the licensed nurses did not follow the facility's Pain Assessment and Management policy. This policy requires a thorough pain assessment, documentation of medication administration, and evaluation of the medication's effectiveness after one hour. The failure to adhere to these procedures resulted in the potential for unrecognized and unrelieved pain for the resident, as well as the risk of medication errors due to inaccurate documentation.
Failure to Implement Care Plan for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident had floor mats at the bedside as indicated in the resident's care plan. This deficiency was identified during a review of the resident's records and an observation in the resident's room. The resident, who was admitted with Alzheimer's disease, unspecified psychosis, unilateral primary osteoarthritis, muscle weakness, and unspecified abnormalities of gait and mobility, was assessed to have severe cognitive impairment and required substantial assistance with various movements and transfers. The resident's care plan, initiated due to a history of falls and generalized weakness, specified the need for floor mats at the bedside to reduce fall-related trauma. During an observation and interview with the Charge Nurse, it was noted that there were no rubber floor mats on either side of the resident's bed, contrary to the care plan's requirements. The Charge Nurse acknowledged that floor mats should have been present as per the care plan. The facility's policy on comprehensive person-centered care plans emphasizes the need to furnish services to maintain the resident's highest practicable well-being, which was not adhered to in this instance.
Failure to Address Resident's Refusal of Care
Penalty
Summary
The facility failed to develop an individualized care plan and conduct an interdisciplinary team conference involving the family member to address a resident's refusal of examination and treatment by a podiatrist and optometrist. This deficiency was identified during a review of the resident's records and interviews with family and staff. The resident, who had severe cognitive impairment and required substantial assistance with mobility and dressing, had active physician orders for podiatry and optometry consults as needed. The resident's care plans for cognitive deficit and vision impairment included interventions to involve the family in decision-making. However, the family was not informed of the resident's refusal to attend appointments with the podiatrist and optometrist on multiple occasions. Interviews with the charge nurse and registered nurse supervisor revealed that the refusals were not documented in the care plan, and the family was not notified, which could have potentially allowed them to persuade the resident to receive necessary care. The facility's policy and procedure for handling refusals of care required that an interdisciplinary team member meet with the resident or representative to address concerns and discuss alternative options. Additionally, the policy mandated prompt notification of the resident's representative and physician regarding changes in the resident's condition or status. The failure to adhere to these policies resulted in a delay of needed services for the resident, which could have contributed to further medical problems.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to adhere to a physician's order and the care plan for a resident, which required the placement of floor mats on both sides of the resident's bed to prevent fall-related injuries. The resident, who had severe cognitive impairment, dementia, bipolar disorder, and difficulty walking, was identified as high risk for falls with a Morse Fall Scale score of 75. Despite these risks and the active physician order dating back to 9/30/2022, the floor mats were not placed as required. During an observation, it was noted that the resident's bed lacked the necessary floor mats, which was confirmed by the Charge Nurse, who was unaware of the reason for their absence. The Director of Nursing acknowledged that the nurses should follow physician orders to ensure resident safety. The facility's policy on fall risk management emphasized the importance of implementing resident-centered fall prevention plans, yet this was not followed in this instance, leading to a potential risk of severe injury for the resident.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents, Resident 82 and Resident 59. Resident 82, who has moderate cognitive impairment and requires dependent assistance for activities of daily living, was observed lying in bed wearing a urine-soaked diaper without a privacy curtain drawn, exposing him to the hallway. Despite multiple observations over a period of time, the resident remained in this undignified state. Interviews with staff confirmed that this exposure and lack of timely care were dignity issues and posed risks for skin breakdown and pressure ulcers. Resident 59, who has an indwelling urinary catheter, was observed with her privacy curtain open and her catheter exposed to passersby. The resident expressed discomfort and a desire to get out of bed. Staff interviews confirmed that the lack of a privacy bag for the catheter was a dignity issue, and the facility's policy emphasized the importance of maintaining resident privacy and dignity. The Director of Nursing also acknowledged the necessity of a privacy bag to ensure the resident feels respected and valued.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, Resident 82 and Resident 67. Resident 82, who has diagnoses including dysphagia, hemiplegia, hemiparesis, and essential hypertension, was observed with the call light on the floor and placed on the side where the resident has paralysis. This made it impossible for Resident 82 to reach the call light, leading to frustration and a feeling of helplessness, especially when needing assistance with incontinence care. Interviews with the resident and staff confirmed the negative impact on the resident's well-being and the increased risk of falls and injuries due to the inability to reach the call light. Similarly, Resident 67, who has severe cognitive impairment and requires assistance with daily activities, was observed with the call light hanging down the side of the bed, out of reach. Staff acknowledged the importance of having the call light within reach to prevent falls and ensure timely assistance. The Director of Nursing Service (DON) emphasized that the call light is a crucial communication tool for residents to call for help and should always be within easy reach. The facility's policy also mandates that call lights be accessible to residents, but this was not adhered to in these cases.
Failure to Provide Preferred Activities to Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 20 and Resident 145, were provided with their preferred activities, which could negatively impact their quality of life. Resident 20, who was admitted with cerebral infarction and hemiplegia, was observed multiple times lying in bed without any engagement in her preferred activities such as reading books, listening to music, or participating in group activities. Despite being able to communicate her preferences, Resident 20 was found staring at the window, napping, or sitting with a bored expression, with no activity personnel present to offer her the activities she enjoys. Similarly, Resident 145, who has diagnoses including dysphagia, hemiplegia, and hypertension, was also not provided with her preferred activities. Her care plan indicated a preference for staying in her room and enjoying activities like reading mystery and romantic books and listening to romantic music. However, observations revealed that Resident 145 was mostly found sleeping, with no evidence of activity personnel engaging her in her preferred activities. Interviews with staff confirmed that the activity personnel had not been consistently visiting Resident 145, and there was no documentation of activities being provided for the month of April 2024. Interviews with various staff members, including a CNA, LVN, and the Activity Director, highlighted the importance of providing residents with their preferred activities to support their mental and emotional well-being. The Activity Director admitted that activities were not consistently provided due to staffing issues, and the Director of Nursing Services emphasized the necessity of offering activities to support residents' psychological and social well-being. The facility's policy on activity evaluation also underscored the importance of promoting residents' physical, mental, and psychosocial well-being through activities tailored to their interests and preferences.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, Resident 17 and Resident 47. Resident 17, who was admitted with acute and chronic respiratory failure, had an order for suctioning as needed for increased mucus production. However, during an observation, it was found that Resident 17's suction machine tubing and yankauer were not dated. Similarly, Resident 47, who was admitted with chronic obstructive pulmonary disease and had an order for oxygen inhalation at 2 liters per minute, was observed using undated oxygen tubing and humidifying water that had not been changed since 4/7/2024. Resident 47 was unsure when the oxygen tubing and water were last changed, and Licensed Vocational Nurse 1 confirmed the oversight, stating that these items should be changed weekly to ensure patency and prevent germ growth. Registered Nurse Supervisor 1 and the Director of Nursing Services both confirmed that the suction machine tubing, yankauer, oxygen tubing, and humidifying water should be dated and changed weekly to maintain their effectiveness and prevent clogging and patency issues. The facility's policy on oxygen administration, revised in 2010, also mandates the regular checking and discarding of used or outdated respiratory supplies. The failure to adhere to these protocols has the potential to compromise the delivery of care and services to the residents involved.
Failure to Provide Accurate and Safe Pharmaceutical Services
Penalty
Summary
The facility failed to provide accurate and safe pharmaceutical services and procedures in several instances. Medications for two residents were not disposed of from the medication cart after being discontinued. Specifically, medications for Resident 39 and Resident 16 were found in the medication cart despite being discontinued. This oversight was confirmed during an observation with LVN 5 and interviews with the DON and LVN 5, who acknowledged that discontinued medications should be removed immediately to prevent accidental administration. The facility's policy on medication storage was not followed, as evidenced by the presence of these discontinued medications in the cart. Additionally, the facility failed to properly transcribe physician's orders for fentanyl transdermal patches into the Medication Administration Record (MAR) for Resident 14. The MAR did not reflect the updated physician's orders, leading to discrepancies in the administration of the fentanyl patches. Interviews with the Consultant Pharmacist, Primary Physician, and LVN 6 revealed that the nursing staff did not update the MAR as required, and the correct order to remove and re-apply the fentanyl patch every 72 hours was not followed. This failure was further compounded by missing signatures on the Controlled Drug Record, indicating that the patches were not properly destroyed as per the facility's policy. The facility also failed to check blood pressure parameters for Resident 148 before administering antihypertensive medication as ordered. During an observation, LVN 3 attempted to administer amlodipine Besylate to Resident 148 without realizing that the resident's systolic blood pressure was below the threshold specified in the physician's order. The DON confirmed that nurses should always check the doctor's orders, including parameters, before administering medication. The facility's policy on administering medications was not adhered to, putting the resident at risk for potential adverse effects such as hypotension and bradycardia.
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 5,216 citations issued within 25 miles in the last 12 months — including the 15 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 San Pedro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seacrest Post-acute Care Center | 0 mi | ★★★★★ | 29 | 0 |
| Providence Little Comp Of Mary Subacute Care Ctr | 0 mi | ★★★★★ | 11 | 0 |
| Palos Verdes Health Care Center | 3.1 mi | ★★★★★ | 24 | 0 |
| Lomita Post-acute Care Center | 4.2 mi | ★★★★★ | 29 | 0 |
| Torrance Memorial Med Ctr Snf/dp | 5.4 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for White Point Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.