Citations in California
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in California.
Statistics for California (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in California
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident with cerebral infarction, DM, and dementia, who had decision-making capacity, had a documented care plan and widely known preference to refuse ADL care from male CNAs and be assisted only by female CNAs. Despite this, nursing assignments for a night shift placed a male CNA in charge of the resident’s ADL care, contrary to the resident’s expressed wishes and the facility’s dignity policy, which commits to honoring resident choices, preferences, values, and beliefs.
A resident with quadriplegia and intact cognition asked a CNA to retrieve food, and the CNA responded angrily, yelling that the resident would not receive anything from him and charging toward the resident with aggressive body language. The resident, in a slow electric wheelchair, reported feeling scared and unsafe, and another resident witnessed the incident. Over subsequent days, the resident showed emotional distress, stayed in bed, avoided social interaction, and told staff she did not feel safe with the CNA. Although multiple staff later described the CNA’s conduct as verbal or emotional abuse, the charge nurse and CNA who first received the complaint did not report it to the administrator as abuse, the administrator did not interview the resident, and the incident was not reported to state authorities or investigated as abuse for several days. During this delay, the CNA, who had known behavioral issues and had been described as rude, resistant, and prone to shouting at residents, continued to be assigned to provide care to dozens of other residents on two units, contrary to facility abuse policies requiring immediate reporting, prompt investigation, and removal of accused staff from resident care.
A resident with quadriplegia and intact cognition reported that a CNA became verbally aggressive and physically intimidating when she requested food, yelling at her, refusing assistance unless she greeted him, and charging toward her in a threatening manner. The resident told staff she was scared and did not feel safe, and documentation showed ongoing emotional distress, withdrawal, and refusal to get out of bed or discuss the incident. Staff such as a CNA, CN, DSDs, and SW later characterized the event as verbal or emotional abuse, but the ADM, serving as abuse coordinator, did not treat it as abuse, did not interview the resident, and relied only on the CNA’s account. The SOC 341 abuse report was not completed and submitted within required time frames, the investigation was not initiated or conducted thoroughly at the time of the allegation, the CNA continued to be assigned to resident care without a documented risk assessment for other residents, and the resident’s increased fearfulness and behavioral changes were not identified as potential indicators of abuse as required by the facility’s abuse policy.
A cognitively intact resident with quadriplegia reported that a CNA became verbally aggressive and physically intimidating when asked to retrieve food from a refrigerator, yelling at the resident and charging toward her with an aggressive posture. Another resident witnessed and corroborated the account, and responding staff observed the resident to be shaking, tense, and stating she was scared and did not feel safe. Although staff on the unit understood the event as abuse, the ADM only interviewed the CNA, did not interview the resident, and did not treat the incident as an abuse allegation. A nursing supervisor reported only the CNA’s version of events to the ADM and did not convey the resident’s statements. The CNA continued to provide care to many residents on subsequent shifts, and the facility did not implement protective measures or follow its abuse policy and regulatory requirements for preventing further potential abuse and thoroughly investigating the allegation.
Surveyors found that a popcorn machine used to serve residents was visibly soiled, with black and brown residue on the kettle lid, rim, and exterior, and a popcorn fragment left on the lid. Activity staff reported they were solely responsible for cleaning the machine and described using only water and disposable napkins or a sponge after use, acknowledging that residue likely remained. The dietary manager assistant and IP stated the machine should be cleaned after each use per the manufacturer’s instructions, which outline specific cleaning and advanced kettle-cleaning steps. Facility policies and job descriptions required that food service equipment be sanitized according to guidelines and manufacturer recommendations, but these were not followed, resulting in contaminated food-contact surfaces for residents.
Staff failed to follow contact isolation requirements and use appropriate PPE for two roommates, one with an active C. diff infection and the other identified as at risk. Despite signage indicating contact precautions and a facility policy requiring gown and gloves based on transmission-based precautions, CNAs entered the shared room without PPE to deliver a meal tray, manipulate the light cord, and reposition a bed, and an LN administered injectable medications while her clothing contacted the bed and linens, all without donning a gown. Staff interviews confirmed lack of PPE use, misunderstanding of when gowns were required, and awareness that both residents were considered under contact isolation, while the DON confirmed the expectation that all staff entering the room and providing care should use gowns and gloves.
Two residents did not receive timely, physician-ordered care for fungal skin rashes. One resident with intact decision-making capacity and no cognitive impairment had standing orders for twice-daily cleansing and application of Triamcinolone cream, and later Nystatin powder plus Triamcinolone to breast, buttock, and perineal areas for candidiasis; TAR review and staff interviews confirmed multiple missed evening doses across two months. Another resident with pneumonia, epilepsy, and moderate cognitive impairment reported an itchy, red, raised groin rash, with documentation that the physician was called and staff were awaiting treatment orders, but records showed no successful physician contact or treatment orders in place until six days later. The DON confirmed that ordered treatments were not fully administered and that the delay in obtaining orders for the rash constituted a delay of care, contrary to facility policies on medication administration and change in condition.
A resident with dermatitis of the trunk and a history of cardiac arrhythmias had physician orders for daily topical ketoconazole and triamcinolone for 30 days, with a care plan goal that symptoms such as scaly, flaky, itchy, red skin would resolve within that period and a specified re-evaluation date. On observation, the resident still had a generalized rash and reported ongoing itchiness, yet review of progress notes showed no documented re-evaluation of the treatment or care plan on the target date. The treatment nurse and DON confirmed that the care plan was not reassessed or revised as required by facility policy, resulting in a failure to update the plan of care based on the resident’s ongoing skin condition.
A resident with chronic kidney disease and decision-making capacity repeatedly requested discharge home and participated in an IDT meeting where the team documented that the resident would remain until full recovery and that the MD would be notified to determine discharge safety. Despite a care plan calling for evaluation of prognosis, pre-discharge planning, and monitoring for distress, staff did not notify the physician, obtain MD orders or progress notes regarding discharge appropriateness, or document specific safety concerns preventing discharge. The resident reported not seeing a doctor since admission and feeling distressed and uninformed about discharge goals, while SS and the DON acknowledged that discharge goals, rationale, and required physician notification were not documented or completed.
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Honor Resident Preference for Female CNA During ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly documented preference not to receive ADL care from male CNAs. The resident, who had diagnoses including cerebral infarction, DM, and dementia, was determined in a recent H&P to have the capacity to understand and make decisions. Her care plan, titled “Resident Refuses Male CNA Care,” specified that she would receive required care while maintaining dignity, comfort, and emotional well-being, and directed staff to assign a female CNA for personal care, document refusals of care, and respect her preference for female CNAs. The resident’s MDS showed she required varying levels of assistance with personal hygiene, dressing, bathing, toileting hygiene, footwear, oral hygiene, and eating, indicating she depended on staff for multiple ADLs. Despite this, review of the nursing assignment sheet for a specific night shift showed that a male CNA was assigned to provide ADL care to this resident. Staff interviews confirmed that the resident’s preference to refuse care from male CNAs was widely known among facility staff. The DON acknowledged that the resident’s preference for female CNA care was in the care plan and stated that this preference should have been honored, regardless of staffing changes due to multiple staff calling out sick. The facility’s undated “Quality of Life – Dignity” policy stated that residents will always be treated with dignity and respect and that the facility is committed to honoring resident choices, preferences, values, and beliefs throughout their stay. The assignment of a male CNA in contradiction to the resident’s expressed and care-planned preference constituted the cited deficiency and was noted as having the potential to affect the resident’s psychosocial well-being.
Failure to Protect Resident From Mental Abuse and Delay in Abuse Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident with quadriplegia from mental abuse and intimidation by a CNA, and failure to recognize, report, and investigate the incident as abuse. The resident, who used a slow-moving electric wheelchair and had a BIMS score of 15/15, asked a CNA to retrieve food from a refrigerator. The CNA responded by demanding that the resident say hello to him if she wanted something, repeating this in an angry manner. When the resident replied that she did not have to say hello if she did not want to, the CNA turned, yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA, and then charged toward her with his chest out and aggressive arm movements. The resident reported feeling scared and defenseless because of her limited mobility and slow wheelchair, and believed the CNA appeared as if he wanted to physically fight her. A second resident witnessed the incident and corroborated the account. Following the incident, the resident called for help and reported to another CNA and the charge nurse that she was scared and did not feel safe with the CNA’s behavior. Staff observations and progress notes documented that the resident appeared in emotional distress at the time of the incident and remained upset and distressed over the following days, including expressing disbelief that the incident had occurred, stating she was not safe with the CNA, and planning to report to the police and Ombudsman. She stayed in bed for several days, refused to get out of bed, avoided social interaction, and declined to keep talking about the incident because she did not want to be retraumatized. Social work and psychotherapy notes documented that she did not feel safe with the CNA, feared he could lose his temper with her or other residents, and that the interaction elicited feelings of unsafety, a sense of being frozen, and led to three consecutive days in bed and avoidance of social interaction. Despite these reports and observations, the charge nurse and CNA who first received the resident’s complaint did not report the incident to the administrator as an allegation of abuse, and the administrator did not interview the resident. The administrator stated she did not consider the incident to be abuse and believed the resident had chosen to file an internal grievance rather than have the incident reported externally. Nursing supervisors did not relay the resident’s statements of fear and emotional distress to the administrator, and one supervisor reported only the CNA’s version of events, omitting the resident’s account. The facility did not complete and submit the SOC 341 abuse report form or report the allegation to the state agency until three days after the incident, and the internal investigation did not begin until that time. During this delay, the CNA, who had a documented history of behavioral concerns noted by the Directors of Staff Development and other staff (including arrogance, resistance to instruction, rudeness, shouting at residents, and unprofessional conduct), continued to be assigned to provide care to residents on two other units, exposing 63 residents to a staff member whose conduct toward the resident had been described by multiple staff as abuse and emotionally distressing. The facility’s own policy defined mental abuse as verbal or nonverbal conduct causing or having the potential to cause humiliation, intimidation, fear, or degradation, including yelling, hovering to intimidate, threatening residents, and depriving a resident of care. Staff interviews, including those of CNAs, the charge nurse, social worker, and Directors of Staff Development, characterized the CNA’s conduct toward the resident as verbal or emotional abuse and intimidation. The facility’s abuse policy required all employees to act as mandated reporters, to immediately report suspected abuse to the administrator and external agencies within specified time frames, to initiate an investigation promptly, and to ensure that staff accused of abuse generally did not have contact with residents during the investigation. These requirements were not followed in this case, leading to a failure to protect the resident from mental abuse and intimidation and a failure to protect other residents from potential abuse. Surveyors determined that this failure to identify and act on the resident’s allegation as abuse resulted in psychosocial harm to the resident, including feeling scared and unsafe, withdrawal from socialization, and ongoing worry, and posed an immediate jeopardy to the safety and well-being of the other residents on the units where the CNA was assigned during the delay in reporting and investigation.
Removal Plan
- Immediately remove any staff member identified as the subject of an allegation involving intimidation, fear, or potential abuse from direct resident care pending investigation.
- Confirm through facility leadership that no residents are currently exposed to staff under investigation.
- Observe the affected resident by nursing staff after the incident and place the resident on monitoring for emotional distress every shift.
- Have the Behavioral Health Program Coordinator attempt to see/assess the affected resident (with follow-up attempts as needed).
- Provide access to facility psychologist and social workers to the affected resident (and all residents) as needed.
- Regardless of investigation type (complaint vs. abuse), if a staff member is an alleged perpetrator, remove the staff member from direct patient care pending abuse investigation results or determination the complaint does not involve abuse.
- Require staff reporting incidents to the Abuse Coordinator to provide thorough and accurate statements based on gathered knowledge, observations, preliminary interviews, and the resident’s psychosocial disposition.
- Report allegations or suspicions of abuse promptly according to required regulatory timelines and submit Form SOC 341.
- Educate staff that they are mandated reporters with the right and obligation to report abuse or suspicion of abuse regardless of others’ opinions.
- Ensure staff are educated and have access to the SOC 341 form and abuse policies/procedures for guidance.
- Provide facility-wide in-service education on staff training for abuse, neglect, and exploitation prevention, with staff on days off/leave/PTO completing education upon return and prior to providing patient care.
- Continue a thorough investigation of the allegations, including resident interviews, staff interviews, witness interviews, employee personnel file review, resident record review, and other items as necessary.
- Submit all investigation results to CDPH within required timelines.
- Have the Administrator/Abuse Coordinator review abuse investigation protocols using the Abuse Investigation Checklist with the Assistant Administrator, DON, ADON, QA nurse, other ADON, and the Behavioral Health Program Coordinator before assuming direct patient care.
Failure to Implement Abuse Policy After Alleged Verbal and Emotional Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse policy regarding identification, reporting, investigation, and prevention of abuse. A cognitively intact resident with quadriplegia, admitted after a motor vehicle accident, reported an incident in which a CNA allegedly acted in a verbally aggressive and threatening manner when she requested food from the refrigerator. The resident stated the CNA demanded that she say hello to him before he would help her, repeated this in an angry tone, then yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA. The resident reported that the CNA then charged toward her with his chest out and aggressive arm movements, in a way that appeared as if he wanted to physically fight her. She stated she was scared because her electric wheelchair moved slowly and she was worried she could not get away from him fast enough. Another resident present confirmed witnessing the incident as described. Following the incident, the resident reported the event to another CNA and a charge nurse, telling them she was scared and did not feel safe with the CNA involved. Progress notes documented that the resident appeared to be in emotional distress on the night of the incident and continued to verbalize disbelief and upset about the incident over the next several days. Notes further showed that she stayed in bed, refused to get out of bed, declined to talk to staff about the incident, and avoided social interaction. The resident later told the social worker she did not feel safe with the CNA being around her and expressed concern that the CNA could lose his temper with her or other residents. A psychotherapy note documented that the resident reported feeling unsafe and frozen during the interaction, spending three consecutive days in bed, and avoiding social interaction to prevent retraumatization. Despite these reports and observations, the facility did not identify, report, or investigate the allegation of abuse in a timely and thorough manner as required by its abuse policy. The SOC 341 abuse report was not completed and faxed to the state agency until days after the incident, and the administrator, who served as the abuse coordinator, stated she did not consider the incident to be abuse and did not interview the resident. The administrator reported that she only interviewed the CNA and relied on information from nursing supervisors, who did not relay the resident’s full account or her expressed fear and emotional distress. Staff interviews revealed that the charge nurse and other staff recognized the incident as verbal or emotional abuse and believed it should have been reported immediately, but this did not occur. Additionally, staffing records showed that the CNA continued to be assigned to provide resident care on two subsequent days after the allegation, and there was no documented assessment of risk to other residents during the investigation period, despite the facility’s policy allowing reassignment of accused staff when there is risk to residents. The facility’s abuse policy required immediate reporting of abuse allegations to law enforcement and regulatory agencies within specified time frames, completion of the SOC 341 by the employee who heard about the abuse, and implementation of effective measures to ensure that further potential abuse did not occur while an investigation was in process. The policy also required internal reporting to the administrator and allowed for moving an accused employee to another assignment if there was risk to residents, and it directed that staff be educated to identify behaviors such as increased fearfulness as potential indicators of abuse. In this case, the facility did not follow these procedures: the administrator was not fully informed of the resident’s statements and emotional condition, the resident’s increased fearfulness and withdrawal were not identified or treated as potential signs of abuse under the policy, and the CNA remained in resident care assignments without documented risk assessment. As a result, the facility failed to implement its abuse policy in the areas of timely reporting, thorough investigation, risk assessment for other residents, and recognition of behavioral indicators of possible abuse.
Failure to Recognize, Report, and Investigate Alleged Verbal Abuse and Protect Resident
Penalty
Summary
The deficiency involves the facility’s failure to recognize, respond to, and report an allegation of verbal and psychological abuse toward a resident, and to protect residents during the investigation. A cognitively intact resident with quadriplegia, as documented by an MDS BIMS score of 15/15 and a diagnosis of quadriplegia due to a motor vehicle accident, reported that a CNA became verbally aggressive when she asked him to retrieve food from the refrigerator. According to the resident, the CNA demanded that she say hello if she wanted something from him, repeated this in an angry manner, then yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA. The resident stated the CNA then charged toward her with his chest out and aggressive arm movements in a manner that appeared as if he wanted to physically fight her, causing her to feel scared and defenseless due to the slow speed of her electric wheelchair. Another resident witnessed the incident and corroborated the reporting resident’s account. Staff who responded immediately after the incident, including a charge nurse and another CNA, observed the reporting resident to be very shaken, visibly in distress, tense, and shaking, and the resident told them she was scared and did not feel safe with the CNA involved. The resident called for help, asked staff not to leave her alone, and reported that the CNA’s raised voice, intimidating body language, and threatening posture made her feel unsafe. One CNA later stated that the resident reported feeling fatigued, refusing to get up, and not socializing after the incident, and that she considered what happened to be abuse. Despite these observations and statements, the facility’s administrative response did not follow its abuse policy or regulatory requirements. The administrator, who was also the abuse coordinator, stated she only interviewed the CNA involved and did not interview the resident, and that she did not consider the incident to be abuse. The administrator reported that nursing supervisors did not tell her the resident was scared or that this was an abuse allegation, and she believed the resident chose to file an internal grievance instead of requesting that the incident be reported to the state agency. A nursing supervisor acknowledged that she reported only the CNA’s version of events to the administrator, did not relay the resident’s statement, and could not remember what the resident had told her. The facility’s records showed that the CNA continued to provide resident care on subsequent days, and there is no indication in the report that the facility implemented protective measures such as removing or reassigning the CNA while the incident was being investigated, contrary to the facility’s abuse policy and the State Operations Manual requirements to prevent further potential abuse and thoroughly collect evidence.
Improper Cleaning and Sanitation of Popcorn Machine Used for Resident Food Service
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation when a popcorn machine used for residents was found visibly soiled and not properly cleaned and sanitized. During observation in the malt shop, the machine’s kettle lid was darkened with uneven black and brown residue, a popcorn fragment was present on the lid, the rim under the lid was stained with patchy black and brown residue, and the exterior of the kettle was covered with similar buildup. The popcorn cart was locked, and activity staff reported they were responsible for cleaning the machine after each use, stating it was cleaned with a sponge and water before being locked. Both the activity assistant and the activity director acknowledged during the observation that the popcorn machine was not clean due to the visible popcorn piece and residue. Additional staff interviews confirmed inconsistent and inadequate cleaning practices. One activity assistant stated they cleaned the popcorn machine after every use with water and a brown disposable napkin, wiping the kettle and lid but believing chemicals would be needed to remove the oily residue and that residue likely remained without thorough scrubbing. The dietary manager assistant and the infection preventionist each stated the popcorn machine should be cleaned after every use, per manufacturer’s guidelines, and that an unclean machine could pose an infection risk and make residents ill. Review of the manufacturer’s instructions showed specific cleaning and advanced kettle cleaning steps, and facility policies and job descriptions for the activity director and infection preventionist required that equipment be maintained in a clean, sanitary manner and that food service equipment be sanitized according to guidelines and manufacturer’s recommendations. The failure to follow these established procedures resulted in the popcorn machine remaining soiled while being used to prepare food for residents.
Failure to Use Required PPE for Residents on Contact Isolation for C. diff
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices, specifically contact precautions and PPE use, for two residents placed under contact isolation for Clostridium difficile (C. diff). One resident, admitted in May 2025 with diagnoses including diabetes mellitus and sepsis, had an active order for contact isolation for C. diff requiring staff to don gown and gloves prior to room entry and care. The roommate, admitted in January 2026 with diabetes mellitus and colostomy status, had a care plan indicating potential for C. diff infection and the need to use infection control principles and contact precautions as indicated. A sign posted at the room door instructed staff to apply gown and gloves before entering. Surveyors observed multiple staff entering and providing care in this isolation room without required PPE. A CNA entered the room without gown or gloves to deliver and set up a breakfast tray for the resident on contact isolation and, at the resident’s request, pulled the light cord with bare hands, later confirming he had touched room surfaces and was unsure which resident the isolation applied to. Two other CNAs entered the same room without gowns to reposition the exposed roommate’s bed and stated they believed gowns were only needed for close contact care involving the urinary catheter. A licensed nurse entered the room without a gown to administer two injectable medications to the resident on contact isolation, during which her clothing contacted the bed and linens; she later confirmed she knew the resident was on contact isolation for C. diff and that she should have used gown and gloves. The DON confirmed both roommates were considered under contact isolation precautions and that all staff entering and providing care to either resident were expected to use gowns and gloves, consistent with the facility’s PPE policy that PPE type is based on transmission-based precautions.
Failure to Administer Ordered Antifungal Treatments and Delay in Obtaining Rash Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered treatments for fungal skin infections were administered as prescribed for one resident. One resident with intact decision-making capacity and no cognitive impairment had physician orders dated 1/26/2026 for cleansing a rash with normal saline, patting dry, and applying Triamcinolone 0.5% cream topically under both breasts every day and evening shift for 14 days to treat candidiasis. Review of the Treatment Administration Record (TAR) for January 2026 showed that the evening doses on 1/27, 1/28, 1/29, and 1/31 were not documented as given. Subsequent physician orders dated 2/9/2026 directed cleansing with normal saline and application of Nystatin powder and Triamcinolone cream to the buttocks and perineal area every day and evening shift for candidiasis. The February 2026 TAR showed missed evening treatments on 2/11, 2/12, and 2/19. During interviews, an LVN and the treatment nurse confirmed that the resident did not receive all ordered evening treatments and doses of Nystatin and Triamcinolone during these periods. The deficiency also includes the facility’s failure to promptly obtain treatment orders for another resident who reported a new itchy rash. This resident, with pneumonia and epilepsy and moderate cognitive impairment, complained on 1/31/2026 of itchiness to the groin area with red, raised rashes. A progress note documented that the physician was called and that staff were awaiting a response on needed treatment. Review of progress notes, TARs for January and February 2026, and the 24-hour report sheet showed no documentation that the physician was successfully reached regarding the rash on that date, and no treatment orders were in place at that time. In a subsequent interview and record review, an LVN stated there was no supporting documentation that nurses were able to reach the physician about the rash identified on 1/31/2026 and that treatment orders were not obtained until 2/6/2026, six days after the initial complaint. The DON, upon review of the TARs, progress notes, and 24-hour report, stated that nurses did not administer all ordered doses of Nystatin and Triamcinolone for the first resident in January and February 2026 and acknowledged that all treatments should have been administered as ordered. The DON also stated that staff should have communicated to the upcoming shift when waiting for physician orders and characterized the six-day delay in obtaining orders for the second resident’s rash as a delay of care. Facility policies on medication administration and change in condition required medications to be administered as ordered and prompt physician notification when there is a need to significantly alter a resident’s medical treatment.
Failure to Re-Evaluate and Revise Dermatitis Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to re-evaluate and revise a resident’s care plan for dermatitis as scheduled. A resident with a history of atrial fibrillation and atrial flutter, who had capacity to make decisions per a prior H&P and later showed moderate cognitive impairment on the MDS, was observed with a generalized rash on the back and reported having the rash for about a year with itchiness, especially at night. Physician’s orders dated 11/21/2025 directed cleansing the rash with normal saline and applying ketoconazole cream every shift and triamcinolone cream on day shift to the trunk for 30 days. A corresponding care plan for dermatitis of the trunk, initiated on 11/21/2025, set a goal that the resident would have no complaints of scaly, flaky, itchy, red skin for 30 days and no allergic reaction to the topical medications, and specified that a re-evaluation should occur on 12/21/2025. Review of the resident’s progress notes for 12/2025 showed no documentation that the treatment and plan of care were re-evaluated on the 12/21/2025 target date. During interviews, the treatment nurse stated that skin assessments are done daily and at the end of treatment, and that when treatment ends staff should notify the wound consultant to determine whether orders should be continued or changed, but acknowledged that this resident’s plan of care was not revised or re-evaluated on 12/21/2025 to determine if the dermatitis had resolved. The DON similarly stated that the treatment nurse should reassess whether a resident’s plan of care and treatment are working and document the re-evaluation in the progress notes, and confirmed that if the care plan was not re-evaluated after the target date, the resident’s skin condition could have worsened. The facility’s comprehensive care plan policy requires measurable objectives, timeframes, and documentation of alternative interventions as needed, but the required re-evaluation and potential revision of the dermatitis care plan were not completed or documented for this resident.
Failure to Notify Physician and Document Discharge Planning for Resident Requesting Return Home
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and to follow through on discharge planning as documented in an Interdisciplinary Team (IDT) meeting for one resident. The resident was admitted with chronic kidney disease and, per a recent MDS, had decision-making capacity and required varying levels of assistance with ADLs, including cleanup assistance for eating and oral hygiene, maximal assistance for toileting, showering, lower body dressing, and footwear, and partial or supervisory assistance for transfers and upper body care. The resident’s care plan, initiated months earlier, included interventions to evaluate and discuss prognosis for independent or assisted living, identify and address limitations and risks, establish and revise a pre-discharge plan, arrange community resources, and monitor for anxiety, fear, and distress. Record review showed that an IDT meeting was held to discuss the resident’s ongoing desire to discharge home, which the resident had been expressing since the prior year. The IDT documented that the resident would remain in the facility until full recovery and that discharge home would occur once deemed safe by the MD, and the IDT notes stated that the physician would be notified regarding the resident’s request and the team’s determination that discharge was not safe. However, as of the survey date, there was no documentation that the physician had been notified, no physician progress note addressing discharge appropriateness, no physician orders related to discharge planning or safety concerns, and no follow-up documentation indicating that any consultation occurred. Interviews confirmed these documentation gaps and failures in communication. The resident reported not having seen a doctor since arrival at the facility and described emotional distress, frustration, and feeling uninformed about discharge goals, discharge planning, and the steps needed to return home. The resident stated that a meeting about going home had occurred but that nothing further was done. The social services staff, who participated in the IDT, stated that the resident was not deemed safe to discharge but could not provide documentation of the specific clinical, functional, or safety factors supporting that conclusion, acknowledged that the resident had decision-making capacity, and admitted she had not updated the resident on discharge goals or notified the physician as indicated in the IDT summary. The DON stated that the resident remained without documented discharge goals or a documented rationale for why discharge home was not feasible and that someone from the team should have notified the MD to evaluate the resident for discharge goals, consistent with the facility’s policy requiring communication of marked physical or psychological changes to the physician for proper management.
Some of the Latest Corrective Actions taken by Facilities in California
- Educated staff on mandated-reporter responsibilities and immediate abuse reporting, including the right/obligation to report suspected abuse regardless of others’ opinions (K - F0600 - CA)
- Ensured staff had access to the SOC 341 form and abuse policies/procedures for reporting guidance (K - F0600 - CA)
- Provided facility-wide in-service education on abuse/neglect/exploitation prevention, with staff on leave completing training upon return and prior to providing resident care (K - F0600 - CA)
- Implemented orientation in-service for newly hired staff on abuse and physical restraints, including review of the Abuse Prevention and Prohibition Program policy, resident rights, immediate reporting requirements, zero-tolerance policy, and documentation requirements (J - F0604 - CA)
- Implemented shift-to-shift reporting of suspected abuse with immediate suspension of involved staff to reinforce timely identification and response (J - F0604 - CA)
- Implemented ongoing manager/RN supervisor rounds on every shift (including weekends/holidays) with continued monthly monitoring after an initial period to ensure residents remained free from restraints and felt safe (J - F0604 - CA)
Failure to Protect Resident From Mental Abuse and Delay in Abuse Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident with quadriplegia from mental abuse and intimidation by a CNA, and failure to recognize, report, and investigate the incident as abuse. The resident, who used a slow-moving electric wheelchair and had a BIMS score of 15/15, asked a CNA to retrieve food from a refrigerator. The CNA responded by demanding that the resident say hello to him if she wanted something, repeating this in an angry manner. When the resident replied that she did not have to say hello if she did not want to, the CNA turned, yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA, and then charged toward her with his chest out and aggressive arm movements. The resident reported feeling scared and defenseless because of her limited mobility and slow wheelchair, and believed the CNA appeared as if he wanted to physically fight her. A second resident witnessed the incident and corroborated the account. Following the incident, the resident called for help and reported to another CNA and the charge nurse that she was scared and did not feel safe with the CNA’s behavior. Staff observations and progress notes documented that the resident appeared in emotional distress at the time of the incident and remained upset and distressed over the following days, including expressing disbelief that the incident had occurred, stating she was not safe with the CNA, and planning to report to the police and Ombudsman. She stayed in bed for several days, refused to get out of bed, avoided social interaction, and declined to keep talking about the incident because she did not want to be retraumatized. Social work and psychotherapy notes documented that she did not feel safe with the CNA, feared he could lose his temper with her or other residents, and that the interaction elicited feelings of unsafety, a sense of being frozen, and led to three consecutive days in bed and avoidance of social interaction. Despite these reports and observations, the charge nurse and CNA who first received the resident’s complaint did not report the incident to the administrator as an allegation of abuse, and the administrator did not interview the resident. The administrator stated she did not consider the incident to be abuse and believed the resident had chosen to file an internal grievance rather than have the incident reported externally. Nursing supervisors did not relay the resident’s statements of fear and emotional distress to the administrator, and one supervisor reported only the CNA’s version of events, omitting the resident’s account. The facility did not complete and submit the SOC 341 abuse report form or report the allegation to the state agency until three days after the incident, and the internal investigation did not begin until that time. During this delay, the CNA, who had a documented history of behavioral concerns noted by the Directors of Staff Development and other staff (including arrogance, resistance to instruction, rudeness, shouting at residents, and unprofessional conduct), continued to be assigned to provide care to residents on two other units, exposing 63 residents to a staff member whose conduct toward the resident had been described by multiple staff as abuse and emotionally distressing. The facility’s own policy defined mental abuse as verbal or nonverbal conduct causing or having the potential to cause humiliation, intimidation, fear, or degradation, including yelling, hovering to intimidate, threatening residents, and depriving a resident of care. Staff interviews, including those of CNAs, the charge nurse, social worker, and Directors of Staff Development, characterized the CNA’s conduct toward the resident as verbal or emotional abuse and intimidation. The facility’s abuse policy required all employees to act as mandated reporters, to immediately report suspected abuse to the administrator and external agencies within specified time frames, to initiate an investigation promptly, and to ensure that staff accused of abuse generally did not have contact with residents during the investigation. These requirements were not followed in this case, leading to a failure to protect the resident from mental abuse and intimidation and a failure to protect other residents from potential abuse. Surveyors determined that this failure to identify and act on the resident’s allegation as abuse resulted in psychosocial harm to the resident, including feeling scared and unsafe, withdrawal from socialization, and ongoing worry, and posed an immediate jeopardy to the safety and well-being of the other residents on the units where the CNA was assigned during the delay in reporting and investigation.
Removal Plan
- Immediately remove any staff member identified as the subject of an allegation involving intimidation, fear, or potential abuse from direct resident care pending investigation.
- Confirm through facility leadership that no residents are currently exposed to staff under investigation.
- Observe the affected resident by nursing staff after the incident and place the resident on monitoring for emotional distress every shift.
- Have the Behavioral Health Program Coordinator attempt to see/assess the affected resident (with follow-up attempts as needed).
- Provide access to facility psychologist and social workers to the affected resident (and all residents) as needed.
- Regardless of investigation type (complaint vs. abuse), if a staff member is an alleged perpetrator, remove the staff member from direct patient care pending abuse investigation results or determination the complaint does not involve abuse.
- Require staff reporting incidents to the Abuse Coordinator to provide thorough and accurate statements based on gathered knowledge, observations, preliminary interviews, and the resident’s psychosocial disposition.
- Report allegations or suspicions of abuse promptly according to required regulatory timelines and submit Form SOC 341.
- Educate staff that they are mandated reporters with the right and obligation to report abuse or suspicion of abuse regardless of others’ opinions.
- Ensure staff are educated and have access to the SOC 341 form and abuse policies/procedures for guidance.
- Provide facility-wide in-service education on staff training for abuse, neglect, and exploitation prevention, with staff on days off/leave/PTO completing education upon return and prior to providing patient care.
- Continue a thorough investigation of the allegations, including resident interviews, staff interviews, witness interviews, employee personnel file review, resident record review, and other items as necessary.
- Submit all investigation results to CDPH within required timelines.
- Have the Administrator/Abuse Coordinator review abuse investigation protocols using the Abuse Investigation Checklist with the Assistant Administrator, DON, ADON, QA nurse, other ADON, and the Behavioral Health Program Coordinator before assuming direct patient care.
Failure to Involve Conservator and IDT in High-Risk Resident’s Discharge to RCC
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate discharge planning for a resident who was a Regional Center client with schizoaffective disorder bipolar type, unspecified psychosis, anxiety disorder, seizures, anemia, and severe cognitive impairment. The resident’s face sheet identified a conservator as the responsible party, and the MDS dated 11/19/2025 documented severely impaired cognitive skills for daily decision-making and dependence on staff for ADLs, with no ability to ambulate independently. The resident had documented high elopement risk and fall risk, including balance problems and decreased muscular coordination. Social Services documentation from 11/10/2025 indicated the resident came from a homeless environment and might need additional help once discharged home with the support of the conservator. An IDT conference on 11/14/2025 included the conservator by phone, but no discharge planning was discussed at that time, and the notes indicated the bed hold policy and discharge plan would be reviewed with the responsible party/conservator. On 1/28/2026, a physician’s order was obtained to discharge the resident to a recuperative care center (RCC). A progress note timed at 1:20 p.m. on that date documented that the resident was discharged and picked up by EMT personnel, with standard safety checks such as identity verification, confirmation of transfer destination, attachment of transfer documents, and securing the resident on a gurney. The same note indicated that a voicemail was sent to the conservator notifying them of the transfer, but there was no documentation of prior discussion, involvement, or consent from the conservator regarding the discharge plan or the choice of RCC. Social Services Staff stated that the resident was conserved under a Public Guardian and that the facility did not discuss the discharge planning or transfer to the RCC with the conservator, and that no IDT meeting was held related to the discharge plan prior to discharge. The DON stated that she and Social Services decided to transfer the resident to the RCC because the resident did not meet skilled criteria and needed a lower level of care where medications would be managed, and acknowledged that the conservator was not involved in the discharge planning or discharge and that there was no IDT meeting conducted for this discharge. The facility also failed to ensure adequate communication and clinical handoff to the receiving RCC. LVN 1 described the expected discharge process as including obtaining a physician’s order, performing a skin assessment, notifying the family or conservator, preparing discharge paperwork, printing the face sheet and medication summary, and contacting the receiving facility. LVN 1 stated these steps were not fully completed for this resident’s discharge, that he was unable to communicate with the conservator or the receiving facility, did not communicate with a receiving nurse, did not perform medication reconciliation, and did not endorse the resident’s medical history to the receiving facility. He reported that paperwork was handed to EMT personnel at the time of discharge and that he failed to verify the type of setting at the RCC to ensure it could meet the resident’s needs. Subsequently, EMS and hospital records documented that the resident was found wandering in the street in the early morning hours, not alert or oriented, with insect eggs on her clothes and hands, and was transported to a general acute care hospital where she was admitted with acute psychosis and altered mental status. Interviews with the conservator, CNA staff, and review of the facility’s discharge planning policy further confirmed that the resident’s discharge occurred without the required involvement of the conservator, without an IDT discharge planning process, and without appropriate clinical communication to the receiving RCC. The facility’s own policy on discharge planning required the Social Services Director or designee to be involved in discharge planning to ensure a safe discharge and successful transition to the next level of care or return home, working with the IDT, physician, resident, and resident’s representative. The policy specified that discharge planning services and any changes to the discharge plan were to be discussed with the resident and, if indicated, the resident’s representative, and documented in the medical record. In this case, interviews and record review showed that the conservator was not involved in selecting the RCC or consenting to the discharge, that no IDT meeting was held to assess the resident’s cognitive, medical, physical, and psychosocial needs prior to discharge to a lower level of care, and that the RCC was not properly notified of the resident’s diagnoses, medications, history of wandering, and risk for falls and seizures prior to transfer. These actions and omissions constituted the deficient practice cited under F-627 for failure to ensure a safe and appropriate discharge for this resident.
Removal Plan
- The DON/designee conducted an immediate clinical review of Resident 1’s status in collaboration with the GACH, including medication reconciliation and continuity of care.
- The IDT (Social Service, DOR, DON, ADON/QA Nurse, DSD, MDS Nurse) met to review root cause analysis and ensure discharge planning criteria/process compliance.
- The IDT (SSD, DON, ADON) conducted a facility-wide review of discharges, focusing on level of care determination, IDT involvement, legal representative notification/consent, safe discharge destination, and medication reconciliation/continuity.
- Require licensed nursing staff to notify the SSD of all resident discharges and have discharge information communicated to the SSD and reviewed during the weekly discharge planning meeting (including assessment of cognitive impairment, elopement risk, behavioral symptoms, conservatorship/legal representative involvement, and discharge planning), with variances corrected immediately.
- Require DON or designee to provide final authorization prior to discharge.
- During weekends/when SSD and DON are not physically present, require the Nursing Supervisor to review discharge documentation, confirm completion of required steps, and notify the SSD and DON for follow-up review.
- Implement a Hard Stop Discharge Protocol using a standardized interdisciplinary discharge checklist; no resident may be discharged until all checklist steps are completed.
- Require final approval by the Administrator or DON for all planned discharges to lower levels of care (including RCFE, ALF, ILF, and recuperative care) upon completion of the Hard Stop checklist.
- Require discharge planning to begin at baseline admission and be reviewed at least 30 days prior to projected discharge, again 7 days prior, and prior to the day of discharge.
- Assign QA Nurse responsibility for resident assessment and participation in the discharge process.
- Assign IDT (SSD, DOR, DON, DSS, QA) responsibility for reviewing discharge planning.
- Assign DON/QA/DON designee responsibility for reviewing clinical readiness and safety prior to discharge.
- Require licensed nursing staff to provide a complete handoff to the receiving provider/facility at discharge (clinical status, medications, care needs, follow-up requirements) and document the handoff in the medical record.
- Require SSD and licensed nursing staff to notify the resident’s guardian/responsible party regarding discharge planning, provide discharge destination options, and document preferences/consent in the medical record.
- Assign SSD responsibility for all discharge notices and documentation (notify resident/guardian/responsible party, document discharge plan and chosen destination, maintain related forms/communications in the medical record, ensure timely completion).
- Require Nursing Supervisor or licensed nursing staff to provide a complete handoff report to the receiving facility at discharge (clinical status, medications, care needs, behavioral considerations, follow-up requirements) and document it in the medical record.
- Require SSD to complete post-discharge follow-up/wellness check within 72 hours to confirm safe arrival, medication/care management, identify concerns, and document follow-up actions.
- Provide in-service training to the DON and Administrator on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety considerations, and compliance monitoring.
- Provide 1:1 in-service and competency validation with the SSD on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety requirements, and documentation expectations.
- Educate all licensed nurses, Social Services staff, and IDT members on CMS discharge requirements, resident rights, safe transitions of care, documentation expectations, legal representative notification, and high-risk discharge criteria; provide training by DON and SSD with attendance logs; include in new hire orientation.
- Audit all resident discharges using the Hard Stop Discharge Checklist (daily for first 2 weeks, weekly for next 4 weeks, then monthly) through QAPI to ensure ongoing compliance.
- Ensure on the day of discharge the licensed nurse provides a complete report/handoff to the receiving facility prior to transfer.
- Have Medical Records review audit findings and report results to DON/ADON/QA team; correct discrepancies timely; report results to the QAPI Committee by DON and SSD.
- Incorporate the discharge process into the facility’s QAPI program, including tracking/trending discharge variances, identifying root causes, implementing corrective actions, and reporting findings to leadership, with a performance goal of 100% compliance.
Failure to Protect Resident From Unauthorized Physical Restraint and Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from physical restraints and abuse. A resident with dementia, Alzheimer’s disease, muscle weakness, gait and mobility abnormalities, and no capacity to make decisions was admitted in August 2025. The resident’s MDS dated 12/8/2025 showed severe cognitive impairment, with the resident rarely understanding and rarely being understood, and being dependent or requiring assistance for most ADLs. A fall risk assessment on the same date identified the resident as high risk for falls with a score of 21. These records established that the resident was cognitively impaired, physically vulnerable, and dependent on staff for care and safety. On the night in question, CNA 1 was assigned to the resident during the 11 p.m. to 7 a.m. shift and remained on duty until after 7 a.m. LVN 1 reported that around 2 a.m. the resident began chanting, which became louder and more frequent. LVN 1 asked CNA 1 to check on the resident; CNA 1 returned and stated the resident was okay and always behaved that way. Approximately 10 minutes later, the resident again began yelling in her own language. At around 2:50 a.m., LVN 1 entered the resident’s room, found the blanket on the floor, and observed the resident lying in bed making wiggly body movements. LVN 1 then saw that the resident’s wrists were firmly tied together in front of her with a long scarf, with no wiggle room and no ability for the resident to move or release her hands. LVN 1 untied the scarf and assessed the resident, noting no visible injury. The facility’s own policies required that any physical restraint be preceded by a licensed nurse’s assessment, IDT involvement, determination of need, identification of the least restrictive device, and appropriate documentation and consent. The restraint policy also stated that residents are to be provided a restraint-free environment and that restraints are not to be used for discipline or staff convenience. The abuse prevention policy stated that each resident has the right to be free from abuse, neglect, and mistreatment, that the facility has zero tolerance for abuse, and that staff accused of abuse, neglect, or mistreatment are to be suspended until the investigation is complete. The DON and Administrator both stated that tying the resident’s hands with a scarf constituted a physical restraint and physical abuse, and the Administrator indicated he believed CNA 1 tied the resident’s hands for the CNA’s convenience because the resident was restless. Despite this, CNA 1, who was suspected of tying the resident’s hands and was found sleeping during that time, was not immediately removed from duty and continued to provide care to the resident until the end of the shift, contrary to the facility’s abuse prevention policy.
Removal Plan
- LVN 1 reported the alleged abuse incident to Human Resources and the Director of Nursing, stating Resident 1 was found with hands bound by a scarf; LVN 1 removed the scarf and notified the Ombudsman.
- The facility suspended CNA 1 pending Human Resources investigation.
- LVN 1 received a written warning for failing to report the incident to the RN Supervisor on duty.
- The facility terminated CNA 1.
- The Director of Staff Development reported CNA 1 to the CNA Licensing Board.
- RN Supervisors conducted rounds on all units to visually observe all residents for any signs of physical restraints, inappropriate devices functioning as restraints, or signs of abuse/neglect; no other residents were identified.
- RN Supervisors conducted another facility-wide sweep of all residents to screen for restraints; no other residents were identified.
- Human Resources and the Administrator suspended LVN 1 for failure to follow facility policy.
- The Assistant Director of Staff Development initiated in-service training for facility staff regarding restraints, with the Assistant DSD and DSD continuing in-services until completion.
- During orientation, the facility will in-service newly hired staff on abuse and physical restraints, including review of the Abuse Prevention and Prohibition Program policy, resident rights, immediate reporting requirements, zero-tolerance policy and requirement to report suspected abuse immediately, and documentation requirements.
- The Director of Nursing created a root cause analysis.
- The Administrator and Director of Nursing instructed staff that there will be immediate removal of staff from duty when abuse/neglect is suspected.
- Shift-to-shift report will include reporting of any suspected abuse and immediate suspension of staff involved.
- Department Managers, Managers of the Day, and the RN Supervisor on duty will conduct daily rounds on every shift (including weekends and holidays) to validate no restraints observed weekly for four weeks, then monthly for two months, to ensure residents feel safe and are free from restraints.
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