Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woods Health Services during CMS and state inspections, most recent first.
Missing Advance Directive Documentation: The facility failed to provide or maintain AD documentation for four residents. Two residents were not given AD information on admission, one resident’s chart lacked a copy of an AD despite records showing a POA/health care authority, and another resident’s AD was missing the signature page. The SSD, AC, and DON all acknowledged the importance of documenting and offering AD information, and the facility policy required written AD information and prominent documentation in the medical record.
A resident with severe cognitive impairment and bowel incontinence went 8 days without a BM being addressed in a timely manner, despite a bowel regimen and a care plan for constipation risk. Another cognitively intact resident had multiple OTC products at the bedside without a physician order or self-administration assessment, and staff stated the facility was not aware of the items. A third resident’s right arm sling was observed positioned incorrectly after a shoulder injury, and RN and CNA staff stated the sling was not providing proper support.
Undated oxygen tubing was found for two residents receiving continuous O2 via NC. One resident with COPD and another resident with acute respiratory failure with hypoxia were both observed on oxygen, but their NC tubing was not properly dated or was overdue for change. Staff stated the tubing should be changed and dated weekly for infection control, and the IP confirmed the NC tubing and humidifier were separate devices that required weekly changes.
CNA 3's annual skills review showed the skill of reporting unusual occurrences was not completed, and the CNA also needed improvement in choking intervention and BP measurement. The DSD said the facility waited to provide a group in-service until all staff skills were finished, while the DON stated a 1:1 review should have been done on the spot when a skill was not met. The facility policy required nursing staff and CNAs to have the competency needed to provide safe resident care and respond to resident needs.
Medication Pass Error Rate Exceeded 5 Percent: A resident with DM II and depression had two medication errors during a morning med pass, resulting in an 8 percent error rate. An LVN prepared the wrong dose of Prozac and failed to prepare and administer the resident’s ordered estradiol vaginal cream. The resident reported the Prozac dose had recently been changed, and the DON stated the five rights of med administration include right patient, medication, dose, route, and time.
Improper beard coverage and low sanitizer concentration in kitchen. The dietary manager was observed preparing food without a beard cover, and a kitchen staff member had a beard net that did not fully cover facial hair. In addition, two of three sanitizer buckets tested at 100 ppm, below the facility’s required 200-400 ppm range, during dishwashing area checks.
Infection Control Lapses With Oxygen Tubing and Unlabeled Personal Care Item: Two residents receiving O2 were observed with nasal cannula tubing on the floor, including one resident with COPD and another with acute respiratory failure with hypoxia. In a shared restroom, an unlabeled perineal and skin cleanser belonging to one resident was stored in the roommate’s niche; the CNA and IP identified it as a personal care item that should be labeled to prevent cross contamination.
Late MDS Submission After Discharge: A resident with Alzheimer’s disease and HTN was discharged, but the PPS discharge MDS was completed late and then mistakenly set to “do not send” instead of being transmitted to CMS/QIES ASAP. The MDS Nurse stated the wrong submission option was selected during the sending process, and the RAI manual requires the discharge assessment to be completed and submitted within the specified timeframe.
A resident with dementia and impaired decision-making had ongoing redness of the left lower eyelid, but the care plan only addressed prior conjunctivitis and was not updated for the chronic eye redness. Staff observed the redness, noted the resident had previously received eye medication, and acknowledged that the existing CP had been resolved even though the resident was still receiving artificial tears and the DON said the condition needed a care plan with interventions and monitoring.
A resident with DM II, hyperlipidemia, and long-term insulin use had a pharmacist MDRR note recommending CMP, fasting lipid panel, and A1c monitoring, but the physician/prescriber response was left blank and the record showed no order or documentation that the recommendation was reviewed or acted on. Staff confirmed there was no evidence the labs were ordered, despite the facility policy requiring physician documentation of review and action on irregularities.
A resident’s IPE was left incomplete because the discharge receipt section was not signed or dated after the resident was transferred to the hospital and later did not return. The resident had COPD with acute exacerbation and HTN, was cognitively intact, and had items of value listed on the IPE, including a wallet, cell phone and charger, computer/laptop/e-reader, hearing aids, and eyeglasses. RN and DON interviews confirmed the family collected the belongings, but no one documented receipt on the form.
A resident with a right lower leg fracture, gait impairment, and generalized weakness fell and was initially assessed with no injury identified. Although the physician and family were notified of the fall, the resident later reported new buttocks pain and received hydrocodone-acetaminophen for 7/10 pain to the right ankle and buttocks. RN and DON interviews confirmed there was no documentation that the new onset pain was promptly reported to the MD as a change in condition.
Failure to Provide Rescue Breaths During CPR: A resident with MI and CVA history was found unresponsive with absent respirations and no palpable pulse. Staff initiated chest compressions, but rescue breaths were not given at the start of CPR because an Ambu bag or CPR shield was not available to the LPNs/CNA, and an RN later had to leave the room to get an Ambu bag. The DON stated CPR required 30 compressions and 2 breaths, and the facility policy required ventilations via Ambu bag or CPR shield.
Inaccurate pain assessment and failure to report new pain after a fall. A resident with a right lower leg fracture, gait impairment, and weakness fell while being assisted after a shower. The record contained conflicting pain documentation, including repeated 0/10 entries despite later charting of 7/10 right ankle and buttocks pain and administration of hydrocodone-acetaminophen. The RN and DON stated the pain documentation should have accurately reflected the resident’s complaints and that the new onset pain should have been promptly reported to the MD.
A resident with a right lower leg fracture, NWB orders, gait impairment, and high fall risk fell during post-shower ADL care after a CNA asked the resident to stand from a shower chair while the floor was still wet and clothing remained around the knees. The resident was barefoot on one foot, no second staff member was present, and staff later described the situation as unsafe; the resident landed on the buttocks and reported pain, with later imaging noting the coccyx was suspicious for a fracture.
The facility failed to ensure nursing staff maintained required competencies and responded appropriately during an emergency. Review of personnel files showed that nearly half of the CNAs lacked current CPR certification, despite job descriptions requiring CPR training and maintenance, and the DSD confirmed that CPR renewals and mock codes were not being maintained or documented. CNA competency evaluations had not been completed annually since 2024, and licensed nurse skill evaluations for an RN and several LVNs were incomplete, missing dates and signatures. One RN’s IV therapy competency was evaluated by an LVN, even though the DON stated IV therapy was outside the LVN scope, while the DON’s job description assigned her responsibility for annual competency training. In a resident emergency involving low oxygen saturation, an RN did not assess the resident, did not obtain full VS, left the bedside to call 911, and did not return or document assessments, while an LVN left the resident alone multiple times instead of using a walkie talkie, administered only 2 L/min O2 without reassessment, did not obtain BP, and failed to document pre- and post-oxygen VS, contrary to facility CPR and oxygen administration policies.
A resident with multiple comorbidities, including traumatic subdural hemorrhage and DM, was found unresponsive but breathing with an O2 sat of 89%. Staff administered oxygen and called 911 but did not obtain the resident’s BP or RR and did not reassess or document O2 saturation after oxygen was started, instead obtaining only a blood glucose of 292 mg/dl. The RN and DON confirmed that in the commotion, a full set of VS was not taken despite facility policy and the SBAR tool requiring detailed assessment, including BP, pulse, temp, RR, oximetry, and finger stick glucose if indicated, during a change in condition.
A resident with dementia, muscle wasting, and type 2 DM, assessed as severely cognitively impaired and needing substantial/maximal assistance with ADLs, had a care plan identifying high fall risk due to confusion and balance problems and requiring a 2-person assist for all transfers using an EZ stand. Despite this, a CNA and the resident’s responsible party reported that the CNA used the EZ stand alone to transfer the resident to the bathroom, contrary to the documented intervention. The DON confirmed that care plans are intended to direct staff interventions and that fall-risk interventions are to be followed, and facility policy required comprehensive person-centered care plans to be developed and implemented for each resident.
The facility did not complete required annual performance evaluations for multiple CNAs, as shown by personnel records indicating that several CNAs had no documented reviews for one or more years despite a written policy requiring annual evaluations by supervisors. The DSD confirmed that no CNA performance reviews had been conducted since she assumed her role, even though she acknowledged they should occur yearly. This deficiency was identified through staff interviews and review of employment records and facility policy.
A resident with a history of atrial fibrillation and hypertension was admitted with a critically low BP, but staff did not notify the physician as required by facility policy. The resident later experienced a fall, and interviews confirmed that staff recognized the need to report such findings but failed to do so, with no documentation of physician notification in the records.
A resident with a history of atrial fibrillation, hypertension, and recent low blood pressure was admitted with clear indicators of high fall risk, including a fall risk bracelet and a high Fall Risk Evaluation score. Despite these factors, staff did not notify the physician of the resident's hypotension or implement additional fall prevention interventions. The resident subsequently slid off the bed while attempting to use a urinal, with persistently low blood pressure documented before and after the fall. Staff interviews confirmed that required notifications and interventions were not completed.
A resident admitted with pneumonia and sepsis died unexpectedly, and the facility did not report the death to CDPH within the required 24 hours under its Unusual Occurrence Reporting policy. The Administrator acknowledged the report was submitted late.
A resident with a left first toe fracture did not receive treatment as ordered by the physician and orthopedic specialist, as staff failed to document or implement buddy taping or splinting of the toe. Nursing staff did not transcribe the orthopedic recommendations into orders, and there was no record of the treatment being provided, contrary to facility policy.
A resident with a surgical wound was admitted without a complete wound assessment or timely treatment order, and wound care was not consistently provided as prescribed. The wound was left uncovered and dressing changes were missed, resulting in the development of an infection that required hospital transfer and treatment.
A resident admitted with a surgical wound on the left hip did not have the wound documented or described by the admitting RN, and subsequent LTC evaluations by staff also failed to include required wound descriptions and measurements. This resulted in incomplete and inaccurate medical records, contrary to facility policy requiring objective, complete, and accurate documentation.
A resident admitted with a healing surgical wound and multiple complex diagnoses did not have a treatment order for the wound included in their care plan until nearly two months after admission. Nursing staff confirmed the omission, and review showed the care plan failed to address the required wound care intervention as outlined in facility policy.
A resident with severe cognitive impairment was administered Seroquel, a psychotropic medication, for psychosis without documented informed consent from the responsible party. Facility staff and policy confirmed that consent was required prior to administration, but records showed the medication was given without this step, leaving the responsible party uninformed about the risks and benefits.
A resident with severe cognitive impairment and multiple diagnoses did not have medication irregularities identified by the pharmacist communicated to their physician. Recommendations regarding GI medications, a statin, and an antipsychotic dose reduction were not acted upon, and there was no documentation of physician review or response, contrary to facility policy.
Staff did not follow Enhanced Barrier Precautions by failing to wear PPE while providing care to a resident on isolation, and two residents' nasal cannula tubing was observed touching the floor, contrary to infection control protocols. Facility staff and leadership acknowledged these lapses, which were not in line with established policies for infection prevention.
A resident with severe visual impairment was unable to access the call light, which was left out of reach, and another resident with multiple medical conditions experienced a significant delay in having their call light answered for needed treatment. Staff and policy confirmed that call lights should be accessible and answered promptly, but these expectations were not met in both cases.
A resident with a history of stroke and other medical conditions was prescribed Plavix, an antiplatelet medication, but the MDS was incorrectly coded to indicate anticoagulant use. The MDS Nurse and DON confirmed that antiplatelet and anticoagulant medications should be coded separately, and the error was identified during record review and staff interviews.
A resident with heart failure and other conditions was admitted with an active hospice order, and both the care plan and staff interviews confirmed ongoing hospice care. However, the MDS assessment did not reflect the resident's hospice status, resulting in inaccurate documentation.
A resident with multiple medical conditions and cognitive impairment was given several medications by an LVN without being informed about the medications, their purposes, or potential side effects. Interviews with the LVN, the resident, and the DON confirmed that the resident was not provided with this information, despite facility policies supporting residents' rights to be informed and involved in their care.
A resident with multiple medical conditions, including heart failure and asthma, was observed receiving a higher oxygen flow rate than ordered via nasal cannula. Although records indicated compliance with the physician's order for three liters per minute, direct observation revealed the resident was receiving four liters, and staff confirmed the error and corrected it. Facility policy and staff interviews emphasized the requirement to follow physician orders for oxygen administration.
A resident with severe cognitive impairment, a history of falls, and dependence for mobility was found with only one floor mat beside the bed, despite a physician order and care plan requiring mats on both sides. Staff interviews and record reviews confirmed the order was not followed, resulting in noncompliance with prescribed safety interventions.
The facility did not post actual nursing hours for all shifts and failed to display nurse staffing information in a location accessible to residents and visitors. Staffing sheets were only available at the nursing station and did not include required details such as total and actual hours worked per shift for licensed and unlicensed staff, as confirmed by interviews with the SA and DON.
Surveyors found that expired food was stored in a kitchen refrigerator and that required sanitation and equipment cleaning logs, including those for sanitizer concentration, ice machine cleaning, and dish machine temperature, were incomplete and missing required managerial review. The dietary supervisor confirmed these lapses and referenced facility policies requiring proper food storage and daily log completion.
A resident's discharge destination was inconsistently documented, with the MDS indicating discharge to a hospital while the Discharge Instruction Form showed discharge to a LTC center. The MDS Coordinator acknowledged the error, and the DON emphasized the importance of accurate records for care planning and post-discharge support.
The facility failed to monitor healthcare personnel for RSV symptoms after exposure to two residents who tested positive. Despite placing the residents in isolation, the Infection Prevention Nurse did not track staff or resident contacts, and the Director of Nursing confirmed no such tracking occurred. The facility's infection control policy lacked procedures for tracking exposures, contrary to CDC guidelines, potentially allowing RSV to spread.
A CNA failed to perform hand hygiene during meal service, moving between two residents without washing hands, which could lead to cross-contamination. One resident had a femur fracture and gastrointestinal issues, while the other had a history of myocardial infarction and UTIs. The facility's policy required handwashing before and after resident care, which was not followed.
A facility failed to accurately complete the infection monitoring form during an influenza outbreak for a resident. The resident was admitted with influenza, pneumonia, and respiratory failure, but the forms inaccurately indicated symptoms before admission. The DON acknowledged the error, noting the importance of accurate documentation for patient care and compliance.
The facility failed to revise care plans and implement new interventions for two residents after multiple falls, despite having policies in place for falls management and care plan revisions. Both residents had documented falls, but their care plans were not updated, as confirmed by staff interviews. This deficiency placed the residents at risk for further falls and injuries.
A facility failed to document the cancellation of a urology consult for a resident with congestive heart failure, bradycardia, and Parkinson's disease. Staff interviews confirmed the cancellation was known but not recorded, violating the facility's documentation policy and leading to communication gaps among staff.
A resident tested positive for Hepatitis A, but the facility failed to report the case to the California Department of Public Health (CDPH), only notifying the County of Los Angeles Department of Public Health. The Director of Nursing was unaware of the requirement to report to CDPH, despite facility policies mandating such reporting for communicable diseases.
A facility failed to adhere to infection control practices when a housekeeper entered a Covid-19 isolation room without required eye protection, and staff left personal tumbler cups in a designated Covid-19 area. The housekeeper did not wear goggles or a face shield as required, and the Infection Preventionist Nurse noted the risk of cross-contamination from the cups, which were improperly stored in the red zone.
The facility failed to answer call lights in a timely manner for seven residents, leading to frustration and potential psychosocial decline. Residents reported waiting up to an hour for assistance, causing frustration and self-reliance for bathroom needs. Staffing shortages and increased resident assignments contributed to the delays, as acknowledged by the DON.
The facility failed to develop comprehensive care plans for three residents, including one with dementia and psychosis, another with diabetes and dysphagia, and a third with severe cognitive impairment. The care plans lacked specific interventions, measurable objectives, and timeframes, leading to potential gaps in care.
The facility failed to follow physician's orders for a resident's antihypertensive medications, administering Losartan and Metoprolol despite blood pressure readings below the specified parameters. This non-compliance with medication administration protocols had the potential to adversely affect the resident's health.
The facility failed to provide sufficient staffing, resulting in delayed toileting and incontinence care for seven residents. Residents reported waiting times ranging from 10 minutes to over an hour for assistance, leading to discomfort and potential health risks. Staff interviews confirmed that call-offs and increased resident assignments contributed to the delays. The facility's policies indicated that call lights should be answered within 3-5 minutes, but the observed delays indicated a failure to meet these standards.
The facility failed to follow proper food storage and preparation practices, with unlabeled and undated food items and cold foods not maintained at the required temperature. This had the potential to cause foodborne illness and affect food quality for residents.
Missing Advance Directive Documentation
Penalty
Summary
The facility failed to provide documentation regarding advance directives for four sampled residents. Resident 8 was admitted with hypertensive heart disease and vascular dementia, and the MDS indicated severely impaired cognition and need for extensive assistance with care. During interview and record review, the Social Services Director reviewed Resident 8’s notarized POA and stated it addressed finances only and did not address health care decisions. The Admissions Coordinator also stated Resident 8’s admission agreement did not address an advance directive and was outdated, and the DON stated offering advance directives was important to know the resident’s wishes when they were able to make that decision. Resident 21 was admitted with sepsis due to enterococcus and UTI. The H&P indicated Resident 21 had the capacity to understand and make decisions, and the MDS was reviewed during the investigation. The Admissions Coordinator reviewed Resident 21’s admission agreement and stated it did not address an advance directive and was outdated. The DON stated offering advance directives was important to know the resident’s wishes when they were able to make that decision. The facility policy stated residents are to be provided written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive upon admission, or the information may be provided to a legal representative if the resident is incapacitated. Resident 20 was admitted and readmitted with acute respiratory failure with hypoxia and dependence on supplemental oxygen. The MDS indicated Resident 20’s cognitive skills for daily decision making were intact. The SSD reviewed Resident 20’s records and stated the resident had a POA (Health Care Authority) and that the facility would ask for a copy, but Resident 20 did not have an advance directive or POA on file in the medical record. Resident 35 was admitted and readmitted with muscle weakness and type 2 diabetes mellitus, and the H&P indicated capacity to understand and make decisions. The SSD reviewed Resident 35’s undated advance directive and stated it should have had a signature page but did not. The facility policy stated advance directives are to be respected in accordance with state law and facility policy, and information about whether a resident has executed an advance directive shall be displayed prominently in the medical record.
Bowel monitoring, OTC medication control, and sling positioning were not properly managed
Penalty
Summary
Resident 6’s bowel movement pattern was not addressed in a timely manner. The resident had diagnoses including difficulty walking and osteoarthritis, was severely cognitively impaired, and was dependent for toileting and most personal care. The care plan identified bowel incontinence, impaired mobility, and risk for constipation, and included bisacodyl suppository 10 mg as needed for bowel management. The medication record showed the resident received a bisacodyl suppository on 5/20/2026, while the bowel elimination task sheet showed a bowel movement on 5/12/2026 and no additional bowel movement until 5/20/2026. During interview, RN 1 stated the lack of bowel movement should have been addressed after three days but was not addressed until 5/20/2026. RN 1 stated that a lack of bowel movement greater than three days could increase the resident’s risk for bowel impaction and could also cause discomfort. The facility’s bowel disorders clinical protocol stated staff and the physician would monitor the individual’s response to interventions and overall progress, including frequency and consistency of bowel movements. Resident 32 had multiple OTC products at the bedside without a physician’s order or a self-administration assessment. The resident had diagnoses including acute MI and colostomy status, and was cognitively intact. During observation, the resident had CVS Arthritis Pain Relief Cream and IcyHot Pain Relief Lidocaine cream at the bedside, and stated there were additional OTC items in the bedside drawer, including stool softener, zinc oxide ointment, ear drops, nasal spray, sore throat spray, and Desitin diaper rash ointment. The resident stated the OTC products were ordered over the phone from CVS and mailed directly to the resident, and stated the facility did not appear to pay attention to the OTC products. RN 1 and LVN 2 stated the facility was not aware of the OTC products and that they should not have been stored at the bedside without a physician’s order and self-administration assessment. The DON stated residents could have OTC drugs when ordered by the physician and after a self-administration assessment, and that the process should also be care planned. The facility’s policies stated residents may self-administer medications only if the attending physician and interdisciplinary team determined they had the decision-making capacity to do so, and that medications found at the bedside without authorization were to be turned over to the nurse in charge. Resident 42’s right arm sling was not positioned properly after a shoulder injury. The resident had diagnoses including congestive heart failure and generalized muscle weakness, was cognitively intact, and required maximal assistance with some ADLs. The physician ordered a right arm and shoulder sling with placement monitored every shift, and the care plan identified the sling and the goal of being free from complications related to the sling. During observation, the resident was wearing the sling with both straps positioned in the front of the neck and right shoulder. The resident stated the sling had to be worn for a few weeks and that moving the neck and shoulder caused pain. CNA 5 stated the sling was not placed correctly because one strap needed to be behind the neck and shoulder. RN 1 stated the sling cushion was not placed correctly for support and that slings must be placed correctly because improper placement could further dislocate the shoulder and not provide support due to instability. The DON stated correct sling placement was important for alignment and proper positioning of the shoulder. The facility’s safety and supervision policy stated interventions should be implemented correctly and consistently.
Undated Oxygen Tubing for Two Residents
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents by not properly dating nasal cannula tubing used for supplemental oxygen. Resident 17 was admitted with COPD and hypertension, had intact cognitive skills, and was ordered to receive oxygen at 4 L/min via nasal cannula continuously, with oxygen tubing and humidifier to be changed every Sunday night shift. Resident 20 was admitted and later readmitted with acute respiratory failure with hypoxia and dependence on supplemental oxygen, had intact cognitive skills, and was ordered to receive oxygen at 2 L/min via nasal cannula continuously. During observation, Resident 17 was awake, alert, and lying in bed receiving oxygen through a humidifier and concentrator. The resident’s humidifier was dated, but the nasal cannula tubing was undated. Later, Resident 17 was observed in the therapy room still receiving oxygen via nasal cannula, and LVN 2 stated the tubing was not labeled. Resident 17 stated oxygen was used 24/7 at 4 L/min, and the nebulizer in the room was kept in a bag labeled with the resident’s name and date. Resident 20 was observed sitting in a wheelchair at bedside receiving oxygen via nasal cannula connected to a concentrator. The tubing had a sticker date, and LVN 2 stated it was over a month old and should have been changed. LVN 2 explained that night shift changed and dated nasal cannula tubing every Sunday and day shift verified the change on Monday mornings. The IP also stated nasal cannula tubing needed to be labeled with the resident’s name, room number, and date, and that the humidifier and nasal cannula were separate devices that had to be changed weekly.
CNA Skills Check Left Reporting Unusual Occurrences Incomplete
Penalty
Summary
The facility failed to ensure that CNA 3 had the appropriate competencies and skill set to care for residents when the annual clinical skills review did not include the skill of reporting unusual occurrences. During a concurrent interview and record review on 5/22/2026, the Director of Staff Development stated CNA 3 was hired on 2/23/2024 and that staff clinical skills were conducted annually. CNA 3's CNA Back to Basics Clinical Skills Checklist, completed on 5/15/2026, showed the CNA needed improvement in choking intervention and blood pressure measurement, and the skill of reporting unusual occurrences was not completed. The Director of Staff Development stated the skill was not completed because the DSD wanted to wait until all staff annual clinical skills were finished so an in-service could be given to all staff at the same time. The DSD also stated a one-on-one in-service should have been provided as soon as possible to ensure CNA 3 was competent to provide proper care because resident safety is first. The DON stated that when a staff member did not meet requirements for a clinical skill during annual skills, the skill needed to be reviewed and a 1:1 in-service should be provided on the spot during the skills check. The facility policy stated nursing staff and CNAs must have the appropriate skills and competency necessary to provide care and assure resident safety and respond to resident needs.
Medication Pass Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. During a medication pass observation for one resident, the facility had two medication errors in 25 opportunities for error, resulting in an 8 percent error rate. The errors involved a Licensed Vocational Nurse preparing the wrong dose of Fluoxetine and failing to prepare and administer the resident’s Estradiol Vaginal Cream that was due during the morning medication pass. The resident involved was admitted and later readmitted to the facility with diagnoses including type 2 diabetes mellitus without complications and depression. The resident’s history and physical indicated the resident had capacity to understand and make decisions, and the MDS indicated intact cognitive skills for daily decision making. The care plan identified antidepressant use related to depression, and the medication orders included Estradiol Vaginal Cream 0.01% daily for vaginal dryness and Prozac 30 mg daily for depression. During the medication pass observation, the LVN prepared medications due at 9:00 AM, placed them in medicine cups, and took one capsule from a Prozac 20 mg bubble pack. The LVN did not prepare the Estradiol Vaginal Cream and later stated it would have been missed if the surveyor had not asked about it. The LVN also stated the resident refused the Prozac because the resident reported the physician had recently changed the dose from 20 mg to 30 mg. The DON stated the five rights of medication administration included right patient, right medication, right dose, right route, and right time, and the facility’s policy required medications to be administered safely, timely, and as prescribed.
Improper beard coverage and low sanitizer concentration in kitchen
Penalty
Summary
Safe and sanitary conditions were not maintained in Kitchen 1 during food preparation and sanitation activities. During observation, the dietary manager was scooping soup from the soup kettle while wearing a beard but not wearing a beard cover. In a separate observation, Kitchen 1 staff member 1 was working in the food preparation area with a beard net that did not fully cover the beard, and hair stubbles were protruding outside the cover. The facility dietician stated that wearing hair and beard covers was important to prevent facial hair from falling into food, and the dietary manager stated beard covers should always be worn correctly when staff have beards because hair follicles could fall into residents' food. The facility also failed to maintain proper sanitizer concentrations in Kitchen 1. Two of three sanitizing solution buckets tested in the dishwashing area read 100 ppm, which was below the facility's stated effective range of 200-400 ppm. Kitchen aid 1 stated the sanitizing solution should be within the correct range to avoid cross-contamination, and the facility dietician and dietary manager both stated the solution buckets should be within recommended ranges to avoid bacterial growth and properly clean and sanitize food preparation areas. The facility's policy required sanitizing solution to be maintained within the effective usage range and changed when it fell out of range.
Infection Control Lapses With Oxygen Tubing and Unlabeled Personal Care Item
Penalty
Summary
The facility failed to implement infection prevention and control practices when two residents receiving supplemental oxygen had nasal cannula tubing on the floor. Resident 55 was admitted with COPD with acute exacerbation and dependence on supplemental oxygen, had an order for oxygen at 2 L/min via nasal cannula continuous every shift, and was observed awake and alert in bed with the oxygen concentrator about three feet away and the tubing on the floor. Resident 20 was admitted and readmitted with acute respiratory failure with hypoxia and dependence on supplemental oxygen, had intact cognitive skills for daily decision making, and was observed sitting in a wheelchair at bedside with oxygen via nasal cannula connected to a concentrator behind the wheelchair and the tubing on the floor; the LVN stated the tubing was on the floor. The IP stated nasal cannula tubing should not be on the floor for infection control and noted a holder had been provided to keep the tubing off the floor. The facility also failed to label a personal care item stored in a shared restroom for two residents. Resident 57 was admitted with pneumonia and severe sepsis without septic shock and had capacity to understand and make decisions. Resident 26 was admitted with anemia and Type 2 DM without complications, had intact cognitive skills for daily decision making, and required substantial/maximal assistance for setup or clean-up assistance with ADLs. Resident 26 stated that Resident 57 used the shared restroom and that Resident 26 could use it with help. During observation in the shared restroom used by Resident 57 and Resident 6, two wall niches were present, with one labeled for the roommate and one labeled for Resident 57. An unlabeled 8 fl oz bottle of perineal and skin cleanser rinse-free was stored on the top wall niche that belonged to the roommate. The CNA stated the cleanser was a personal care item belonging to Resident 57 and that such items should be labeled with the resident's room number and bed to prevent cross contamination. The IP stated the cleanser was a personal care item for private area use and should be labeled with the resident's room and bed number so the item would not be used by the wrong resident, especially in a two-bed room.
Late MDS Submission After Discharge
Penalty
Summary
The facility failed to submit and transmit Resident 2’s discharge MDS assessment to CMS within the required timeframe after the assessment was completed. Resident 2’s record showed a discharge from the facility on 2/23/2026, and the MDS summary identified that date as the target date for the assessment. The MDS itself was completed on 3/10/2026, which was later than the discharge target date, and the assessment was not transmitted as required. During interview and record review, the MDS Nurse stated that while sending the assessment, the wrong option was selected and “do not send” was triggered instead of sending it to CMS. The resident’s history and physical indicated the resident did not have the capacity to understand and make decisions, and the admission record showed diagnoses including Alzheimer’s disease and hypertension. The facility’s Administrator stated the facility followed RAI rules and regulations regarding MDS, and the RAI manual reviewed by surveyors stated that the Part A PPS discharge assessment must be completed within 14 days after the end date of the most recent Medicare stay and submitted within 14 days after the MDS completion date.
Incomplete Care Plan for Ongoing Eye Redness
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed for one sampled resident with multiple diagnoses including unspecified dementia with behavioral disturbance and type 2 diabetes mellitus. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills for daily decision making and dependence to partial/moderate assistance with ADLs. The resident also had an active physician order for artificial tears to the left eye three times weekly. During observation, the resident was sitting in a wheelchair at the bedside with a red left lower eyelid and stated not knowing why it was red. A CNA stated the left eye was still red and had previously been “glued shot,” and that the resident had received medication to the eye and it got better. Review of the care plan showed it addressed impaired visual function related to conjunctivitis and had been initiated when the resident was receiving eye ointment, but staff stated the conjunctivitis treatment had ended and no active care plan existed for the ongoing left eye redness. The MD stated the redness was chronic and being treated with artificial tears, and the DON stated the red left eyelid was a problem that required a care plan with interventions and monitoring. The facility policy stated comprehensive person-centered care plans with measurable objectives and timetables were to be developed and revised as residents’ conditions changed.
Pharmacist MDRR Recommendation Not Addressed
Penalty
Summary
The facility failed to ensure that irregularities identified in the Monthly Drug Regimen Review were acted upon for one sampled resident. Resident 5 was re-admitted with diagnoses including Type 2 Diabetes Mellitus, hyperlipidemia, and long-term insulin use. The resident’s MDS dated 3/25/2026 indicated severely impaired cognition and dependence for toilet use, personal hygiene, and showers/baths. A note from the facility pharmacist, printed 3/12/2026, asked the attending physician/prescriber to consider ordering a CMP, fasting lipid panel, and A1c based on Resident 5’s medications. The physician/prescriber response section was left blank, and there was no documentation in the record showing that the physician ordered the labs or otherwise documented agreement or disagreement with the pharmacist’s recommendation. During record review, the IP stated there was no physician order or documentation showing the labs were ordered, and the RN and DON stated the pharmacist’s recommendations were important for monitoring medications. The facility policy stated that the attending physician documents in the medical record that the irregularity has been reviewed and what action, if any, was taken.
Incomplete Inventory of Personal Effects Documentation
Penalty
Summary
Medical records were incomplete for one sampled resident because the Inventory of Personal Effects (IPE) was not signed or dated to show that the resident’s personal belongings were picked up by family after discharge. The resident had been admitted and readmitted with diagnoses including COPD with acute exacerbation and essential HTN, and the MDS indicated intact cognitive skills for daily decision making, partial/moderate assistance with ADLs, and the H&P stated the resident had capacity to understand and make decisions. The IPE listed items of specific value, including a wallet, cell phone and charger, computer/laptop/e-reader, hearing aids, and eyeglasses. The form was signed by the resident on admission only, with the discharge certification left blank. RN and DON interviews confirmed the resident did not return to the facility after transfer to the hospital, that family later came to collect the resident’s belongings, and that no one had signed the IPE to document receipt of the items.
Failure to Report New Pain After Fall
Penalty
Summary
The facility failed to promptly notify the physician of a change in condition for one resident after a fall on 4/23/2026. The resident was admitted with diagnoses including a displaced bimalleolar fracture of the right lower leg, gait and mobility abnormalities, and generalized muscle weakness. The resident’s MDS indicated intact cognition and substantial to maximum assistance needs for bathing, lower body dressing, and mobility. After the fall, the resident was assessed and documented as having no injury identified at that time, and the physician and family were notified of the fall. Later that day, the resident was given hydrocodone-acetaminophen for a complaint of 7/10 pain to the right ankle and buttocks. The MAR and progress notes documented the medication administration, and the post-fall assessment recorded a pain rating of 0/10. During record review and interviews, RN 1 stated the resident’s new onset buttocks pain following the fall was not documented as being reported to the physician. RN 1 stated that new pain after a fall should be assessed and reported because it represents a change in condition or possible injury requiring further evaluation and intervention. The DON also stated the resident’s new onset pain should have been immediately assessed and promptly reported to the physician as a significant change in condition and potential injury requiring timely evaluation and intervention.
Failure to Provide Rescue Breaths During CPR
Penalty
Summary
CPR was not provided in accordance with the facility’s policy for one resident who was found unresponsive. The resident had been admitted with diagnoses including myocardial infarction and cerebral infarction, and the history and physical indicated the resident did not have the capacity to understand and make decisions. According to the nursing progress notes, a CNA found the resident unresponsive at 12:35 PM, an LVN assessed the resident and found respirations absent and carotid pulse non-palpable, and CPR was initiated. The record and staff interviews showed that rescue breaths were not provided when CPR began. The LVN stated chest compressions were started but rescue breaths were not given because there was no Ambu bag or mouth cover available. Another LVN stated the emergency cart did not have an Ambu bag and rescue breathing was not performed. The CNA also stated rescue breaths were not provided because nursing staff did not have an Ambu bag or mouth cover. RN staff later stated the resident was on nasal cannula oxygen because the emergency cart did not have a non-rebreather mask, and the RN had to leave the room to get an Ambu bag. The DON stated staff were required to provide 30 chest compressions and 2 rescue breaths during CPR, use an Ambu bag to deliver rescue breaths, and provide rescue breaths by mouth-to-mouth before the emergency cart arrived. The DON also stated CPR should not be performed without a backboard. The facility policy required staff to check for breathing and pulse, initiate BLS, and provide 2 breaths via Ambu bag or CPR shield after 30 chest compressions. The report states that an Ambu bag and a non-rebreather oxygen mask were available in the emergency cart at the time of the event, yet rescue breaths were not provided at the start of CPR.
Inaccurate pain assessment and failure to report new pain after a fall
Penalty
Summary
Licensed nurses failed to accurately assess and document a resident’s pain status after a fall, and the resident’s new onset buttocks pain was not communicated to the primary physician. The resident was admitted with diagnoses including a displaced bimalleolar fracture of the right lower leg, gait and mobility impairment, and generalized muscle weakness. The resident’s MDS indicated intact cognition and substantial to maximum assistance needs for bathing, lower body dressing, and mobility. After the resident fell while being assisted following a shower, the facility documented the event in a change in condition evaluation and post-fall assessment. The record showed conflicting pain documentation on the same day: one assessment recorded pain as 0/10, while later skilled charting and progress notes documented pain rated 7/10 in the right ankle and buttocks, with hydrocodone-acetaminophen administered for that complaint. Subsequent documentation again recorded pain as 0/10. The post-fall assessment also documented that the physician and family were notified of the fall and that pain was 0/10. During interview, the RN stated the resident’s records showed repeated documentation of 0/10 pain assessments following the fall, but the progress note documented medication administration for 7/10 right ankle and buttocks pain. The RN stated pain documentation should accurately reflect the resident’s pain complaints, location of pain, and reassessment findings. The DON stated the resident’s new onset pain following the fall should have been immediately assessed and promptly reported to the physician because it represented a significant change in condition and potential injury requiring timely evaluation and intervention. The DON also stated staff are expected to accurately document the resident’s reported pain level, location of pain, and reassessment findings, especially following a fall or change in condition.
Unsafe post-shower transfer and dressing care led to resident fall
Penalty
Summary
The facility failed to ensure adequate safety precautions during ADL care for a resident who had been admitted with a displaced bimalleolar fracture of the right lower leg, gait and mobility impairment, and generalized muscle weakness. The resident’s MDS indicated intact cognition but substantial to maximum assistance was required for showering, lower body dressing, and mobility. The resident was also assessed as a high fall risk and had a physician order for non-weight bearing on the right foot for 4 to 6 weeks. On 4/23/2026, after the resident had a shower, CNA 1 assisted the resident back to the room in a shower chair for a scheduled beauty salon appointment. According to the resident, CNA 1 removed the protective bag from the CAM boot, the resident was barefoot on the left foot, and the resident’s pants and brief were around the knees when asked to stand from the shower chair. The resident stated standing on one foot was difficult because of the non-weight-bearing order and the clothing position, and the resident recalled slipping and falling onto the buttocks. The resident also stated the floor may still have been wet. CNA 1 stated the resident was asked to stand while CNA 1 dried the buttocks area, that no additional staff were present, and that the resident slipped and fell while standing. CNA 1 stated water residue was observed on the floor after the fall and acknowledged the floor should have been completely dry and safe before asking the resident to stand. CNA 2 stated the resident was already on the floor when arriving to assist and observed the floor was wet, the resident’s pants were around the knee area, and the resident was not wearing non-skid socks or shoes on the left foot. LVN 1 stated the resident had known non-weight-bearing orders and required two-person assistance for transfers, and that having pants and undergarments around the knees while asking the resident to stand created a safety concern and increased fall risk. The incident was documented as a fall with pain reported later that day, and a radiology addendum later noted the coccyx was suspicious for a fracture.
Failure to Maintain Nursing Staff Competency, CPR Certification, and Appropriate Emergency Response
Penalty
Summary
The facility failed to ensure nursing staff demonstrated and maintained competency to safely provide care and services in accordance with professional standards. Review of CNA personnel files showed that 16 of 34 CNAs did not have current CPR certification, despite the facility’s CNA job description requiring CPR training after employment and maintenance of CPR certification. The Director of Staff Development (DSD) stated the facility did not require CNAs to maintain current CPR certification, acknowledged CNAs were hired with valid CPR that was allowed to expire, and confirmed there were no mock code drills documented in staff files. The DON stated she did not know if CNAs were required to be CPR certified but agreed they should be, and stated that the risk of CNAs not being CPR certified could lead to residents’ death. Record review further showed that CNA competency evaluations were not completed annually. CNA files indicated the last competency skills evaluations were done in 2024, and the DSD confirmed she had not completed annual competency evaluations since then, stating that annual skills competency was the method to determine if a CNA was competent to work. The DON stated the DSD was responsible for yearly CNA competency evaluations and that without these evaluations, CNAs might perform patient care not according to facility policies and procedures. For licensed nurses, review of Licensed Nurse Skill Evaluations revealed incomplete documentation for one RN and four LVNs, with missing evaluator initials, employee initials, and dates. The DON confirmed that these evaluations must be fully completed with initials and dates to be valid and stated she was not aware they were incomplete. Additional review of a Licensed Nurse Skill Evaluation for one RN showed that this RN was evaluated for IV therapy by an LVN, even though the DON stated LVNs were not allowed to work with IVs because it was outside their scope of practice. The DON reported she had an LVN assist her with yearly Licensed Nurse Skill Evaluations because she needed help, despite her job description stating she was responsible for ensuring all nursing personnel received annual competency training. In a separate resident emergency event, an RN and an LVN did not follow facility policy and expected emergency procedures. The RN, after being notified by an LVN that a resident had low oxygen saturation, did not assess the resident, did not obtain full vital signs, left the bedside to call 911, did not return to the resident’s room, and did not document vital signs or assessments before or after oxygen administration. The LVN reported the resident “did not look good,” obtained an oxygen saturation of 89%, left the resident alone twice (including to get the crash cart) instead of using the provided walkie talkie to call for help, administered oxygen at 2 L/min without increasing it, did not recall rechecking oxygen saturation, did not check blood pressure because she was busy, and did not document vital signs or assessments before or after oxygen therapy. The DON stated that during an emergency the RN’s role was to assess the resident and delegate tasks, that vital signs must be taken to determine stability, that residents should not be left alone because CPR might be needed, and that staff were expected to use walkie talkies in emergencies. Facility policies on CPR and oxygen administration required staff to be trained in CPR/BLS, participate in mock codes, assess residents before and during oxygen therapy, obtain and document vital signs and lung sounds, and document all assessment data and oxygen therapy details.
Failure to Complete and Document Full Assessment During Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to complete and document a thorough assessment and monitoring of a resident who experienced a change in condition and was found unresponsive. The resident had been admitted with diagnoses including traumatic subdural hemorrhage without loss of consciousness, repeated falls, diabetes mellitus, and muscle weakness, and was documented as lacking capacity to make decisions and being dependent on staff for most ADLs. On the night in question at approximately 11 pm, the charge nurse and other staff found the resident unresponsive but breathing, with an O2 saturation of 89%, a pulse of 61, and a temperature of 97.5°F. According to the incident note and SBAR, oxygen was administered for the low O2 saturation, and 911 was called. However, the resident’s BP and RR were not obtained at that time, and there was no documentation of the resident’s O2 saturation after oxygen was started. Staff instead obtained a blood sugar of 292 mg/dl. The records show that paramedics arrived at approximately 11:07 pm, assessed the resident, and initiated CPR, which was later discontinued when the resident was pronounced dead at 12 am. The SBAR later documented an O2 saturation of 96% on room air at 1:44 am and repeated the blood sugar of 292 mg/dl at 2:05 am, but these values did not reflect reassessment at the time of the initial change in condition. Interviews with the RN and the DON confirmed that when the resident was found unresponsive, staff focused on administering oxygen and calling 911 and did not obtain a BP or RR, and did not reassess or document the O2 saturation after oxygen was given. The DON acknowledged that it was important to obtain a full set of vital signs and finger stick glucose as part of the assessment during a change in condition, but that this was not done in this emergency. Review of the facility’s “Change in a Resident’s Condition or Status” policy and the SBAR Communication Form showed that nurses were expected to make detailed observations and gather relevant information, including BP, pulse, temperature, RR, oximetry, and finger stick glucose if indicated, prior to notifying the provider, which did not occur in this case.
Failure to Follow Care Plan Requiring Two-Person Assist With EZ Stand Transfer
Penalty
Summary
Surveyors identified a deficiency in the implementation of a comprehensive person-centered care plan when staff did not follow the documented transfer assistance requirements for a resident. The resident had been admitted with diagnoses including type 2 diabetes mellitus, muscle wasting and atrophy, and dementia, and an MDS assessment showed the resident was severely impaired in cognitive skills and required substantial/maximal assistance for bathing, dressing, toileting hygiene, oral hygiene, and personal hygiene. The resident’s care plan, developed and later revised due to high fall risk related to confusion and balance problems, specified the intervention to use a 2-person assist for all transfers with an EZ stand. Despite this care plan intervention, a CNA reported, and the resident’s responsible party confirmed, that on a specified evening the CNA used the EZ stand alone to transfer the resident to the bathroom, without a second staff member assisting. The DON acknowledged that the purpose of the care plan was to communicate interventions staff should use to address resident needs and that interventions related to fall risk should be followed by staff. The facility’s policy on comprehensive person-centered care plans stated that a care plan with measurable objectives and timetables must be developed and implemented for each resident, but in this instance the intervention requiring two staff for EZ stand transfers was not implemented as written.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete required annual performance reviews for four sampled CNAs, contrary to its policy and the Director of Staff Development’s (DSD) stated expectations. Review of CNA 1’s employment record showed hire on 4/25/2024 and a last performance review on 11/4/2024, with no review documented for 2025. CNA 2’s record showed a last performance review on 12/30/2024, with no review documented for 2025. CNA 4, hired on 7/19/2007, had a last performance review dated 12/28/2023, with no reviews documented for 2024 or 2025. CNA 5, hired on 10/16/2023, had a last performance review on 2/12/2024, with no review documented for 2025. In an interview on 2/10/2026, the DSD stated that performance reviews should be done annually and acknowledged that she had not completed any performance reviews for CNAs since starting in April 2025. Review of the facility’s September 2020 policy titled “Job Descriptions and Performance Evaluations” confirmed that annual performance reviews are required to be completed by the employee’s direct supervisor. This failure had the potential to result in CNAs providing improper care, making clinical errors, and causing resident injury, as identified by the surveyors based on the interview and record review.
Failure to Notify Physician of Resident's Critically Low Blood Pressure on Admission
Penalty
Summary
Facility staff failed to notify a resident's physician of a significantly low blood pressure (BP) reading upon admission. The resident, who had a history of atrial fibrillation and hypertension, was admitted with an initial BP of 64/40 mm/Hg. Despite this abnormal finding, there was no documentation or evidence that the physician was informed of the low BP, as confirmed by interviews with nursing staff and review of progress notes. The facility's policy required that hypotension, defined as BP less than 100/60 mm/Hg, be reported to the physician. On the evening of admission, the resident was found on the floor after slipping off the bed while attempting to use a urinal. At the time of the fall, the resident's BP remained low at 65/41 mm/Hg. Subsequent BP readings taken every 15 minutes showed gradual improvement, but the initial hypotensive episode was not communicated to the physician. Interviews with staff indicated awareness that such low BP readings should be reported, but the responsible nurse did not do so, citing being overwhelmed by multiple admissions. The Director of Nursing confirmed that there was no documented communication with the physician regarding the resident's low BP and acknowledged that staff should have monitored and reported the abnormal vital sign. The lack of physician notification was not documented in the resident's records, and the facility's policy on BP measurement and reporting was not followed in this instance.
Failure to Implement Fall Risk Interventions for Resident with Hypotension
Penalty
Summary
Facility staff failed to implement necessary interventions to reduce the risk of falls for a resident who was identified as high risk upon admission. The resident had multiple diagnoses, including atrial fibrillation and hypertension, and was admitted with low blood pressure. Upon admission, the resident was wearing a yellow bracelet indicating fall risk, and the initial blood pressure reading was significantly below the facility's defined threshold for hypotension. Despite these indicators, there was no documentation that the resident's physician was notified of the low blood pressure, nor were additional interventions implemented to address the increased fall risk. On the day of the incident, the resident's Fall Risk Evaluation score was 13, confirming high risk status, and the resident required moderate to substantial assistance for mobility and toileting. Later that evening, the resident attempted to use a urinal located on the right side of the bed and slid off the bed onto the floor. At the time of the fall, the resident's blood pressure remained critically low, and subsequent monitoring showed persistently low readings. The resident reported occasional dizziness and spinning sensations when turning, although did not recall feeling dizzy immediately before the fall. Interviews with facility staff, including an LVN and the DON, confirmed awareness of the resident's fall risk and low blood pressure, but acknowledged that the physician was not notified and that monitoring and interventions were not initiated prior to the fall. Review of facility policies indicated that hypotension and fall risk should prompt evaluation and communication with the physician, but these steps were not documented or carried out in this case.
Failure to Timely Report Unexpected Resident Death
Penalty
Summary
The facility failed to follow its Unusual Occurrence Reporting policy by not reporting an unexpected resident death to the State Licensing Agency within 24 hours of identification. Resident 1 was admitted with diagnoses including pneumonia and sepsis, and the History and Physical indicated the resident had the mental capacity to make medical decisions. The Nurses' Note documented that Resident 1 died, and during interview the Administrator stated the death was considered an unusual occurrence because it was not expected and acknowledged that the report was submitted past the 24-hour requirement. The facility policy stated that all unusual occurrences, including unexpected resident deaths, must be reported to CDPH within 24 hours.
Failure to Implement and Document Physician-Ordered Toe Fracture Treatment
Penalty
Summary
A resident with multiple diagnoses, including disorders of bone density and muscle wasting, was admitted to the facility and later sustained an acute fracture of the left first toe, as confirmed by x-ray. The physician ordered the first toe to be taped to the second toe until an orthopedic consult, and the orthopedic specialist subsequently recommended buddy taping or splinting the toe for four to six weeks. However, there was no documentation indicating that the toe was taped as ordered, nor was there evidence that the orthopedic recommendations were transcribed into physician orders or followed after the consult. During observations and interviews, staff were unable to confirm if or when the resident's toes were taped, and the nurse did not transcribe the orthopedic recommendations into the resident's orders. The facility's policies required documentation of treatments and adherence to physician orders, but these were not followed in this case. The lack of documentation and failure to implement the prescribed treatment had the potential for the resident's injury to worsen.
Plan Of Correction
Immediate corrective action: Following observations on 6/20/2025, resident 1's toe was checked and buddy taped. Treatment records were updated, and staff in-serviced to ensure checking and taping were completed per the order summary report. Identifying other potentially affected: On 6/23/2025, the DON and Medical Records conducted a random review of three residents having treatment orders and observations. Audits and physical observation revealed successful evidence of completion. No additional concerns were noted. Measures for systemic change: Between the dates of 6/23/2025 and 6/27/2025, the DON provided in-services to licensed nurses regarding carrying out physician orders and proper completion of buddy taping and documentation of doing so for Resident 1's left toes. Monitoring for compliance: The DON and/or RN Supervisor will visually check Resident 1's toe for proper buddy taping regularly until follow-up physician orders discontinue the need. Successful completion of items above:
Failure to Provide Timely and Consistent Wound Care Leads to Infection
Penalty
Summary
A resident was admitted to the facility with a history of multiple left hip surgeries, including a recent procedure that resulted in a large surgical wound. Upon admission, the admitting RN failed to conduct a complete wound assessment and did not document the presence or condition of the surgical wound in the clinical admission record. Additionally, the RN did not obtain a treatment order for the wound at the time of admission, leaving the wound uncovered and without prescribed care for ten days. The facility's policies required a thorough admission assessment, including skin and wound evaluation, and prompt communication with the attending physician to obtain necessary treatment orders, but these steps were not followed. After a treatment order was eventually obtained, there were further lapses in care. On three consecutive days, the assigned LVNs did not implement the prescribed wound care treatment, as evidenced by blank entries in the medication administration record and confirmation from staff interviews. The wound dressing was not changed during this period, and the wound was left unattended, contrary to the treatment plan. The wound care specialist later confirmed that the wound had not been properly managed and that the dressing had not been changed for several days. As a result of these failures, the resident's surgical wound developed an infection, which was confirmed by laboratory testing and medical evaluation after the resident was transferred to an acute care hospital. The infection was attributed to inconsistent and inadequate wound care, including the lack of a timely treatment order and missed dressing changes. The facility's own staff, including the DON, wound care specialist, and infection preventionist, acknowledged that the required assessments and treatments were not performed according to policy, and that these omissions contributed to the resident's wound infection.
Failure to Document and Maintain Accurate Wound Records
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted with a surgical wound on the left hip. Upon admission, the responsible RN did not document the presence or description of the resident's left hip wound in the clinical admission record, despite the resident's history and physical indicating a healing wound and the Minimum Data Set noting the need for surgical wound care. The RN confirmed that wound assessments, including descriptions and measurements, should be documented at admission to allow for proper monitoring. Additionally, facility staff did not document the description or measurements of the resident's left hip wound in the long-term care evaluations on multiple subsequent dates. The Director of Nursing acknowledged that staff should have included this information in the evaluations. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, but this was not followed, resulting in incomplete and inaccurate records for the resident.
Failure to Include Wound Treatment Order in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with a healing surgical wound on the left hip. The resident had diagnoses including acute osteomyelitis of the left femur, infection and inflammatory reaction due to an internal left hip prosthesis, and dysphagia. Upon review, it was found that the resident required surgical wound care and was dependent on staff for several activities of daily living. Despite these needs, the care plan did not include a treatment order for the left hip wound until nearly two months after admission. Interviews with nursing staff confirmed that a treatment order for the surgical wound was not obtained at the time of admission, and the care plan initially failed to address this critical intervention. The facility's policy required that care plans include measurable objectives and timetables to meet each resident's needs, and that all residents with wounds have a wound treatment order included in their care plan. The omission of the wound treatment order in the care plan was identified during record review and staff interviews.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to obtain informed consent from the responsible party prior to administering a psychoactive medication, Seroquel, to a resident with severe cognitive impairment. The resident, who had diagnoses including Parkinson's disease, dementia, and a history of falls, was unable to make medical decisions. Despite this, Seroquel was ordered and administered for psychosis manifested by visual hallucinations and aggression, without documented evidence that the responsible party was informed of the risks and benefits or that consent was obtained. Record reviews confirmed that the medication was given on multiple occasions, and both the LVN and DON acknowledged that informed consent was required for psychotropic medications, as per facility policy. The facility's policy specified that the physician must inform the resident or representative and obtain consent before use of such medications. The lack of documented consent meant the responsible party was not given the opportunity to make an informed decision regarding the resident's treatment.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified during the Monthly Drug Regimen Review (MDRR) by the facility's pharmacist were acted upon for one resident. Specifically, the pharmacist made recommendations regarding the continued use of gastrointestinal medications (Famotidine and Pantoprazole), the reconsideration of Simvastatin, and a gradual dose reduction for the antipsychotic medication Seroquel. In each instance, there was no documentation that the resident's physician was informed of the pharmacist's recommendations or that any action was taken in response. Record reviews showed that the pharmacist's notes to the attending physician regarding these medications were left blank in the section for the physician's response, indicating no documented agreement or disagreement with the recommendations. Interviews with facility staff, including a hospice RN, RN supervisor, and the DON, confirmed that the pharmacist's recommendations were not communicated to the physician as required. The facility's policy states that such irregularities should be reported to the physician within a specified timeframe and that the physician should document their review and actions taken. The resident involved had significant cognitive impairment and multiple diagnoses, including dementia with psychotic disturbances, anxiety, and depression. The lack of follow-through on the pharmacist's recommendations resulted in the potential for unnecessary medication administration, as there was no evidence that the physician was made aware of or addressed the identified medication irregularities.
Failure to Follow Infection Control Practices and Proper Handling of Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several instances involving two residents. For one resident with multiple diagnoses, including pressure-induced deep tissue damage and congestive heart failure, staff did not follow Enhanced Barrier Precautions (EBP) as required. Despite signage indicating the need for gloves and gowns during high-contact care activities, a certified nurse assistant was observed providing face hygiene care without wearing any personal protective equipment (PPE). Both the Infection Preventionist Nurse and the Director of Nursing confirmed that PPE should have been used for residents on isolation precautions. Additionally, the facility did not ensure that nasal cannula (NC) tubing used for oxygen delivery was kept off the floor for two residents. One resident, who was dependent for personal hygiene and had an order for continuous oxygen, was observed with their NC touching the floor while in bed. The attending licensed vocational nurse acknowledged that this was inappropriate for infection control. Similarly, another resident with intact cognition and an as-needed oxygen order was found with their NC tubing on the floor. The nurse present and the Director of Nursing both recognized this as an infection control risk and stated that the tubing should be replaced. A review of facility policies indicated that oxygen delivery devices must be kept clean and changed as needed, and that PPE is required during certain care activities to prevent exposure to bodily fluids. The facility's in-service training also emphasized the importance of proper storage of personal belongings to prevent contamination. These observations and interviews demonstrate lapses in adherence to established infection control protocols, specifically regarding the use of PPE and the handling of oxygen delivery equipment.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident with severe visual impairment and failed to answer a call light in a timely manner for another resident. In the first instance, a resident who was legally blind and dependent on staff for activities such as toilet hygiene and bathing was observed sitting in a wheelchair beside the bed, with the call light placed in the middle of the bed and out of reach. The resident expressed difficulty in locating the call light due to blindness and stated a desire to have it within reach. Staff interviews confirmed the resident's blindness and the expectation that the call light should be accessible, especially for residents with visual impairments. Facility policy also indicated that call lights should be accessible to residents. In the second instance, a resident with diagnoses including a stage 3 pressure ulcer, diabetes, and dysphagia, and who had intact cognition, activated the call light for assistance with treatment. The call light outside the resident's room and at the nursing station remained lit and unanswered for approximately 11 minutes before being addressed by a nurse. The resident reported dissatisfaction with the wait time. Staff interviews confirmed that call lights should be answered within three to five minutes, with a maximum of ten minutes, and that both licensed and unlicensed staff are responsible for responding. Facility policy supported the expectation for prompt response to call lights.
Incorrect MDS Coding of Anticoagulant Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident regarding the use of anticoagulant medication. The resident, who had a history of hemiplegia, hemiparesis following a cerebral infarction, diabetes mellitus, and generalized muscle weakness, was admitted and had an order for Plavix (clopidogrel), an antiplatelet medication, to be administered daily for a cerebrovascular accident. The MDS, dated shortly after admission, incorrectly indicated that the resident received anticoagulant medication. During interviews and record reviews, it was clarified by the MDS Nurse that Plavix is classified as an antiplatelet, not an anticoagulant, and should not have been coded under the anticoagulant section (N0415E) of the MDS. The DON confirmed that accurate medication documentation on the MDS is essential for proper care planning and that anticoagulant and antiplatelet medications are coded separately due to their different mechanisms and uses. The CMS RAI User's Manual also specifies that antiplatelet medications should be coded distinctly from anticoagulants.
Inaccurate MDS Assessment of Hospice Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's hospice status. The resident was admitted with diagnoses including heart failure, depression, and anxiety disorder, and had an active physician order for hospice care from the time of admission. The resident's care plan and order summary both indicated hospice care, and interviews with the resident, a Licensed Vocational Nurse, and the MDS Coordinator confirmed that hospice services had been provided since admission. However, the MDS assessment did not indicate that the resident was on hospice care while residing in the facility. This discrepancy was identified during a review of the resident's records and confirmed through staff interviews. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, and federal regulations mandate that the assessment accurately reflect the resident's status. The inaccurate coding of the MDS assessment resulted in a failure to properly document the resident's hospice status.
Failure to Explain Medications Prior to Administration
Penalty
Summary
The facility failed to ensure that medications, their purposes, and potential side effects were explained to a resident prior to administration. During an observation, an LVN administered multiple medications to a resident without providing explanations about the medications, their intended uses, or possible side effects. The resident, who had diagnoses including pulmonary embolism, diabetes mellitus, and dementia, was documented as lacking capacity to understand and make decisions, and required substantial to maximal assistance with activities of daily living and was dependent for mobility. Interviews with the LVN, the resident, and the Director of Nursing confirmed that the practice of explaining medications prior to administration was not followed in this instance. The resident expressed a desire to know what medications were being given and their purposes, stating it would have reduced confusion and provided a sense of choice. Facility policies reviewed indicated that residents have the right to be informed about their care and to participate in care planning and treatment, as well as to be treated with dignity and respect.
Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including heart failure, asthma, and dysphagia did not receive oxygen therapy in accordance with the physician's order. The resident was ordered to receive continuous oxygen at three liters per minute via nasal cannula, with the care plan specifying that the oxygen flow should be checked every four hours. However, during an observation, the resident was found to be receiving four liters per minute. The attending LVN confirmed the discrepancy and adjusted the oxygen flow to the ordered amount. Record reviews showed that documentation indicated the resident was receiving the correct amount of oxygen and that checks were being performed as required, but direct observation contradicted this. Interviews with nursing staff and the DON confirmed that oxygen administration should follow the physician's order and that only licensed nurses are permitted to adjust oxygen levels. Facility policies also required staff to verify and set oxygen delivery to the prescribed flow rate.
Failure to Implement Physician Order for Bilateral Floor Mats
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician's order for floor mats to be placed on both sides of a resident's bed. The resident, who had diagnoses including Alzheimer's disease, dementia, and a history of repeated falls, was assessed as having severely impaired cognitive skills and required substantial to maximal assistance with activities of daily living and was dependent for mobility. During observation, only one safety mat was found on the left side of the bed, despite the physician's order and care plan specifying floor mats on both sides to prevent injury in the event of a fall. Interviews with facility staff, including an LVN and the DON, confirmed that the physician's order for bilateral floor mats was not followed. The care plan and job descriptions for both LVNs and RNs indicated the requirement to comply with physician orders and implement care plans. The failure to place floor mats on both sides of the bed was directly observed and verified through record review and staff interviews.
Failure to Post Accurate and Accessible Nurse Staffing Information
Penalty
Summary
The facility failed to post the actual nursing hours for all shifts on specified dates and did not ensure that the staffing information was displayed in a prominent location accessible to residents and visitors. Observations revealed that the staffing sheet was only posted at the nursing station and not in an area readily accessible to residents and visitors. Additionally, the posted staffing information did not include the total and actual hours worked per shift for both licensed and unlicensed staff responsible for resident care. Interviews with the Staffing Assistant and the Director of Nursing confirmed that the only nursing staffing postings were at the nursing station and that actual hours worked per shift were not posted as required. The facility's policy indicated that nurse staffing data, including actual hours worked, should be posted daily for each shift in a prominent location. However, this was not followed, resulting in nurse staffing information being inaccessible to visitors and lacking required details.
Deficient Food Storage and Incomplete Sanitation Logs
Penalty
Summary
The facility failed to ensure proper food storage and maintain sanitary conditions in the kitchen. During an observation, five beef base containers labeled with a past best if used by date were found stored in a walk-in refrigerator. The dietary supervisor confirmed that food past its use-by date should not be stored and should be discarded to prevent potential foodborne illness, in accordance with the facility's policy and procedure. The policy specifically states that foods past the use by, sell-by, best-by, or enjoy by date should be discarded to maintain food safety and prevent contamination. Additionally, a review of kitchen logs revealed incomplete documentation for sanitation and equipment cleaning. The sanitation bucket log lacked records for several time points and was missing the manager's initials in the weekly review section. The ice machine cleaning log showed the ice machine was not cleaned as required, and the dish machine temperature record was missing checks and manager initials. The dietary supervisor acknowledged the importance of accurate and daily completion of these logs for regulatory compliance, infection control, and quality assurance, as outlined in the facility's policies.
Inaccurate Documentation of Discharge Disposition
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's discharge disposition in the medical record. A review of the resident's records showed inconsistencies: the Admission Record indicated admission with diagnoses including atrial fibrillation, shortness of breath, and muscle weakness. The Discharge Planning Review noted the resident requested discharge to another LTC center, and the Discharge Instruction Form confirmed discharge to a LTC center. However, the Minimum Data Set (MDS) documented the resident as being discharged to a short-term general hospital. During interviews, the MDS Coordinator acknowledged incorrectly documenting the discharge destination in the MDS, while the Discharge Instruction Form reflected the correct LTC center destination. The Director of Nursing confirmed that accurate documentation in the medical record is essential for quality care and impacts the development of the care plan and post-discharge support. The facility's policy requires that documentation be objective, complete, and accurate. The discrepancy between the MDS and the Discharge Instruction Form resulted in incomplete and potentially misleading information regarding the resident's discharge status.
Failure to Monitor RSV Exposure Among Staff and Residents
Penalty
Summary
The facility failed to investigate and monitor healthcare personnel for signs and symptoms of Respiratory Syncytial Virus (RSV) after exposure to two residents who tested positive for RSV. Resident 1 was admitted with hypertensive heart disease and chronic kidney disease, and tested positive for RSV after exhibiting cough symptoms. Resident 2, admitted with dependence on supplemental oxygen and muscle weakness, also tested positive for RSV. Both residents were placed on isolation after their positive test results. However, the Infection Prevention Nurse (IPN) did not maintain a list of staff or residents who had close contact with the infected residents, and the Director of Nursing (DON) confirmed that there was no tracking of such contacts. The facility's policy and procedure for infection control lacked procedures for tracking close contacts or potential exposures. The IPN was unaware if two staff members who called off work due to not feeling well had close contact with the infected residents. The facility's failure to track and monitor close contacts of the infected residents was contrary to the CDC's guidelines, which recommend active surveillance to identify additional ill residents or healthcare personnel. This deficiency had the potential to spread RSV to other residents and staff within the facility.
Inadequate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to maintain its infection prevention and control program for two sampled residents by not ensuring proper hand hygiene during meal service. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene before entering Resident 1's room, after assisting with the lunch tray, or after exiting the room. Subsequently, CNA 1 handled a coffee pot at a shared station without performing hand hygiene and then entered Resident 2's room to provide a coffee cup, again without performing hand hygiene. This sequence of actions had the potential to transmit infectious microorganisms between residents. Resident 1 was admitted with diagnoses including a left femur fracture, gastrointestinal hemorrhage, and muscle wasting, with moderately impaired cognition and dependency on assistance for activities of daily living. Resident 2 had a history of myocardial infarction, urinary tract infection, and difficulty walking, with decision-making capacity dependent on context. The facility's policy required handwashing before and after direct resident care and contact with potentially contaminated substances, which was not adhered to in this instance, as confirmed by interviews with CNA 1 and the Infection Preventionist Nurse.
Inaccurate Infection Monitoring Form During Influenza Outbreak
Penalty
Summary
The facility failed to accurately complete the infection monitoring form during an influenza outbreak for a resident. The deficiency was identified during a review of the resident's Admission Record, which indicated that the resident was admitted on 12/16/2024 with diagnoses including influenza, pneumonia, and respiratory failure. However, the Infection Monitoring Forms dated 12/13/2024 and 12/14/2024 inaccurately indicated that the resident was already in the facility and showing symptoms of a cough, despite the resident not being admitted until 12/16/2024. During an interview with the Director of Nursing (DON), it was revealed that the infection monitoring in the facility was not initiated until 12/17/2024 for all residents, and the dates on the forms were inaccurately completed. The DON acknowledged the importance of ensuring that forms are accurately completed in healthcare, as they directly impact patient care, safety, compliance, and operational efficiency. The facility's policy and procedure on Charting and Documentation, dated 7/2017, emphasized that documentation in the medical record should be objective, complete, and accurate.
Failure to Revise Care Plans After Multiple Falls
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding falls management and care plan revisions, resulting in a deficiency. Specifically, the facility did not revise the care plans or implement new interventions for two residents after they experienced multiple falls. Resident 1, who was admitted with diagnoses including congestive heart failure, bradycardia, and Parkinson's disease, had several falls documented on SBAR Communication Forms. Despite these incidents, there were no revisions made to Resident 1's care plan to address the falls. Similarly, Resident 2, who was admitted with Parkinson's disease and dementia, also experienced multiple falls as documented on SBAR forms. The facility's records showed that no care plan revisions or new interventions were implemented following these falls. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that care plans should be revised after each fall, but this was not done for Residents 1 and 2. The facility's policies and procedures, including the Falls Management Program and Comprehensive Person-Centered Care Plans, emphasize the need for ongoing assessments and care plan revisions when there is a significant change in a resident's condition. The failure to revise care plans and implement new interventions after falls placed the residents at risk for further falls and injuries, as the facility did not follow its established protocols to mitigate these risks.
Incomplete Documentation of Resident's Urology Consult
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Charting and Documentation,' resulting in incomplete documentation for a resident. The resident, who was admitted with diagnoses including congestive heart failure, bradycardia, and Parkinson's disease, had a scheduled urology consult that was not documented in the medical records. The absence of documentation regarding the cancellation of the urology consult appointment led to a lack of communication among facility staff about the resident's care. Interviews with facility staff revealed that the cancellation of the urology consult was known but not recorded in the resident's chart. Both a Licensed Vocational Nurse and Social Services staff acknowledged the importance of documenting such changes to ensure all staff are informed about the resident's care status. The facility's policy requires that all services, progress, and changes in a resident's condition be documented to facilitate communication among the interdisciplinary team, which was not followed in this instance.
Failure to Report Hepatitis A Case to CDPH
Penalty
Summary
The facility failed to report a communicable disease, specifically Hepatitis A, to the California Department of Public Health (CDPH) for a resident who tested positive. The resident, who had been admitted to the facility with diagnoses including congestive heart failure, bradycardia, and Parkinson's disease, was found to have a high level of Hepatitis A antibodies during a test conducted at a general acute care hospital. The hospital's infection preventionist informed the facility of the positive test result, but the facility only reported the case to the County of Los Angeles Department of Public Health and not to the CDPH. The Director of Nursing (DON) admitted during interviews that they were unaware of the requirement to report the case to the CDPH. The facility's policy and procedure documents, which were reviewed, indicated that unusual occurrences, such as outbreaks of communicable diseases, should be reported to appropriate agencies within 24 hours. However, the facility did not follow this protocol in the case of the resident with Hepatitis A. The failure to report the disease to the CDPH had the potential to hinder proper and timely investigation of the communicable disease.
Infection Control Deficiencies in Covid-19 Isolation Area
Penalty
Summary
The facility failed to implement proper infection control practices to prevent the spread of Covid-19. A housekeeper entered a Covid-19 isolation room without wearing the required eye protection, such as a face shield or goggles, as indicated by the signage outside the room. This signage, provided by the County of Los Angeles Public Health, specified that personal protective equipment, including eye protection, must be worn before entering the room. The housekeeper acknowledged not wearing the necessary eye protection, which is a breach of the facility's policy on standard precautions. Additionally, three tumbler cups belonging to staff were found on the handrail in the red zone, an area designated for residents who tested positive for Covid-19. The Infection Preventionist Nurse confirmed that these cups should not be left on the handrails due to the risk of cross-contamination, which could potentially lead to the spread of infection throughout the facility. The facility's in-service training on infection control emphasized the importance of proper storage of personal belongings, indicating that items such as coffee cups and water bottles should not be left in hallways or resident areas.
Failure to Answer Call Lights Promptly
Penalty
Summary
The facility failed to answer call lights in a timely manner for seven residents, leading to frustration and potential psychosocial decline. Resident 2, who was dependent on staff for toileting, dressing, and bathing, reported waiting up to an hour for assistance, causing frustration and self-reliance for bathroom needs. Resident 15, who required substantial assistance, was observed waiting 15 minutes for help with a bedpan, and Resident 31 reported waiting more than 10 minutes for call light responses, which they considered too long. Resident 148, who was dependent on staff for various needs, reported waiting one to two hours for assistance, leading to prolonged periods in soiled briefs and concerns about skin health. Resident 149's representative stated that the resident, who had bowel issues, waited 15 minutes for call light responses, resulting in incontinence and the need for frequent clothing changes. Resident 150 also reported waiting up to an hour for assistance with soiled briefs, and Resident 30 mentioned that staff often promised quick returns but did not follow through. Interviews with staff, including CNA 1 and the DON, revealed that staffing shortages and increased resident assignments contributed to the delays. The DON acknowledged that call lights should be answered within 5 to 10 minutes and that longer waits could lead to urinary tract infections, skin breakdown, and negative impacts on residents' dignity and psychosocial well-being. Facility policies emphasized the importance of prompt call light responses to maintain resident dignity and care standards.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential gaps in their care. For Resident 16, who was diagnosed with dementia and unspecified psychosis, the facility did not create a care plan to address the use of Depakote Sprinkles, a medication prescribed for bipolar mania. This omission was confirmed during an interview with an LVN, who acknowledged that a care plan was required to monitor the medication's effectiveness and potential adverse reactions. For Resident 25, who had diagnoses including Type 2 Diabetes and dysphagia, the facility did not individualize the care plan to address the resident's nutritional needs and difficulty chewing. Despite a recommendation from a Registered Dietician for a puree diet due to dental issues, the care plan remained generalized and did not reflect specific weight goals or interventions. Both the RD and an LVN confirmed that the care plan should have been tailored to meet the resident's specific needs. Resident 11, who had severe cognitive impairment and was dependent on assistance for daily activities, had a care plan for the risk of altered fluid balance that lacked measurable objectives and timeframes. The Director of Nursing acknowledged that the care plan needed to be individualized to help the resident maintain optimal functioning. The facility's policy and procedure on care plans emphasized the need for measurable objectives and timeframes, which were not met in these cases.
Failure to Follow Physician's Orders for Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that Resident 46 received treatment and care in accordance with professional standards of practice by not following the physician's orders for the administration of antihypertensive medications. Specifically, the facility did not adhere to the prescribed parameters for holding medications based on the resident's blood pressure readings. On multiple occasions, Losartan and Metoprolol were administered despite the resident's blood pressure being below the threshold specified in the physician's orders, which could have adversely affected the resident's health status. Resident 46, who had a history of essential hypertension, hypertensive heart disease with unspecified congestive heart failure, and unspecified atrial fibrillation, was admitted to the facility with specific medication orders. The orders included holding Losartan if the systolic blood pressure (SBP) was less than 120 mmHg and holding Metoprolol if the SBP was less than 100 mmHg or the heart rate was less than 60 beats per minute. However, the Medication Administration Record (MAR) indicated that these medications were administered even when the resident's blood pressure readings were below the specified parameters. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the medications were given incorrectly on several dates, including 2/19/24, 2/24/24, 2/5/24, 2/23/24, and 2/26/24. The facility's policies and procedures for medication administration were not followed, as the staff did not check the physician's orders and parameters prior to administering the medications. This failure to follow the prescribed orders had the potential to result in harmful changes to the resident's blood pressure, compromising their health and safety.
Staffing Shortages Lead to Delayed Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide sufficient staffing, resulting in delayed toileting and incontinence care for seven of 16 sampled residents. This deficiency was observed through multiple interviews, record reviews, and direct observations. Residents reported waiting times ranging from 10 minutes to over an hour for assistance with toileting and changing soiled briefs. These delays were corroborated by staff interviews, which revealed that staffing shortages and call-offs contributed to the prolonged response times. The Director of Nursing (DON) acknowledged that call lights should be answered within 5 to 10 minutes, and delays could lead to urinary tract infections (UTIs) and skin breakdowns. Resident 2, who was admitted with diagnoses including congestive heart failure and dysphagia, reported waiting up to an hour for assistance, leading to self-toileting despite fall risks. Resident 15, with hypertension and legal blindness, waited 15 minutes for help with a bedpan. Resident 30, diagnosed with Parkinson's disease and dementia, also experienced long waits for assistance. Resident 31, with a history of UTIs, reported similar delays. Resident 148, who had a lumbar vertebra fracture, waited up to two hours for help with changing wet briefs, causing discomfort and potential skin issues. Resident 149, with COPD and dementia, faced 15-minute waits, leading to incontinence incidents. Resident 150, admitted with enterocolitis due to C. diff, reported waiting up to an hour for brief changes, resulting in sore and irritated skin. Staff interviews confirmed the facility's staffing issues. CNA 1 and CNA 2 mentioned that call-offs and increased resident assignments led to longer wait times for residents. LVN 1 expressed emotional distress due to the staffing shortage, noting that new hires often did not stay. The facility's policies indicated that call lights should be answered within 3-5 minutes, with a maximum wait time of 10 minutes. The facility assessment highlighted the need for prompt response to bowel/bladder services to maintain continence and promote resident dignity. However, the observed delays and staff admissions indicated a failure to meet these standards, resulting in compromised resident care.
Deficiencies in Food Storage and Temperature Control
Penalty
Summary
The facility failed to follow safe and proper food storage and preparation practices in the kitchen, as observed during a survey. Specifically, food items were found unlabeled and undated, including a jar of peanut butter, individual servings of chocolate pudding, containers of cut-up fresh fruits, dinner rolls, and bins of yellow and red onions. The Utility Worker (UW) acknowledged that the facility's practice was to label food items immediately upon opening to prevent serving spoiled food that could make residents sick. Additionally, cold foods such as macaroni salad were not maintained at the required temperature of 41 degrees Fahrenheit or below, with observed temperatures of 44 and 45 degrees Fahrenheit. The Executive Chef (EC) confirmed the importance of maintaining proper food temperatures to ensure food safety and quality for residents. The facility's policies and procedures (P&P) for food and supply storage, as well as refrigerated storage life of foods, were reviewed and indicated the necessity of labeling and dating food items and maintaining cold food temperatures at 41 degrees Fahrenheit or below. However, the facility's Temperature Log and Checklist (TLC) did not consistently document food items with corresponding temperatures, and cold items were not always placed on ice as required. The deficiencies observed in food labeling and temperature control had the potential to cause foodborne illness and affect the quality and palatability of food served to residents.
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 3,605 citations issued within 25 miles in the last 12 months — including the 9 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 La Verne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Casa Bonita Convalescent Hospital | 1.2 mi | ★★★★★ | 1 | 0 |
| Claremont Care Center | 1.7 mi | ★★★★★ | 14 | 0 |
| Landmark Medical Center | 2.2 mi | ★★★★★ | 26 | 0 |
| Mount San Antonio Gardens | 2.3 mi | ★★★★★ | 1 | 0 |
| Inland Valley Care And Rehabilitation Center | 2.6 mi | ★★★★★ | 64 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Woods Health Services.
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 July 2026) and official state health department websites.