Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dept Of State Hospitals - Metropolitan Snf during CMS and state inspections, most recent first.
The facility failed to define resident‑to‑resident acts as abuse in its P&P and training, causing multiple resident‑to‑resident physical and alleged sexual assaults to be treated only as "altercations" rather than abuse. In one case, a highly dependent resident with a trach, G‑tube, and vision loss was punched in the face while sleeping by a resident with schizophrenia and a violent history, who alleged the other resident tried to have sex with him; staff did not classify this as physical or sexual abuse, did not initiate an abuse investigation, and delayed reporting to the state. In another case, a non‑ambulatory resident at high risk for violence kicked a resident with gait instability and a healing femur fracture, who then punched him three times in the face; this was not recognized as abuse, was reported late, and no enhanced monitoring or medication changes were implemented despite subsequent aggression. A third incident involved two residents with known DTO histories and moderate violence risk, where one struck the other in the chin during a verbal altercation; again, the event was not treated as abuse, reporting and SOC 341 completion were delayed, and behavioral care plans were missing or outdated despite ongoing aggressive behaviors. These failures, rooted in P&P and training that explicitly excluded resident‑to‑resident acts from abuse definitions, led to missed screening, protection, investigation, and timely reporting, and resulted in an Immediate Jeopardy finding under F607.
A resident with significant medical fragility, including a trach and G-tube, was punched in the face while sleeping by another resident with schizophrenia and a documented history of assault and moderate risk for violence. Staff and medical records showed the aggressive resident had previously attempted to hit staff, reported hearing voices to hurt others, and stated he would continue attacking people to secure discharge. Despite these known risks and facility policies requiring individualized treatment plans and monitoring for danger to others, the aggressive resident was not adequately supervised or managed, allowing him to enter the vulnerable resident’s room and inflict a facial laceration requiring wound care.
Surveyors found that staff were inadequately trained to recognize and report abuse when one resident punched another, causing a facial laceration requiring medical attention, and stated he did so because the other resident tried to have sex with him. Multiple RNs and supervisory staff reported that their annual abuse training addressed only staff-to-resident abuse and that they did not consider resident-to-resident physical or sexual incidents to be abuse. Review of the facility’s policies and training materials confirmed that definitions of physical, psychological, verbal, and sexual abuse were limited to actions by someone other than another patient, resulting in resident-to-resident abuse not being identified or reported as required.
The facility failed to timely report multiple resident-to-resident abuse allegations as required by its own policy and regulatory standards. In three separate incidents, one resident punched another in the face causing a laceration after an alleged unwanted sexual advance, two residents engaged in a physical altercation involving kicking and repeated punching, and another resident allegedly punched a peer in the chin following a verbal dispute. These events were reported to the state survey agency days after they occurred instead of within the mandated 2-hour window, and the PRA was not notified of any of the physical or sexual abuse allegations.
Two residents were involved in an incident where one resident with schizophrenia punched another medically complex, wheelchair-dependent resident in the face while he was sleeping, causing a laceration requiring medical attention, and stated he did so because the other resident tried to have sex with him. Nursing and clinical staff documented the injury and allegation but did not conduct further questioning, did not treat the physical or alleged sexual assault as abuse, and did not complete required SOC 341 abuse reports or notify the Patients’ Rights Advocate. Psychiatrists did not promptly evaluate the residents in relation to the allegation, and the facility reported the events to the state agency several days later instead of within the required 2-hour window, and did not submit investigation results within 5 working days as required by facility policy and regulations.
A resident with cognitive impairment and seizure history, identified as high risk for falls, was able to manipulate and open the zipper of an enclosure bed due to staff not properly securing it or a zipper malfunction. The resident subsequently fell from the bed despite being on 15-minute safety checks, as staff failed to ensure the bed was properly secured in accordance with facility policy.
A resident with a mental health diagnosis disclosed past physical and sexual abuse to a psychologist, but the psychologist did not report the allegation or complete required documentation as mandated by facility policy. Multiple staff confirmed that no incident report or notifications to authorities were made, resulting in a delay in the investigation process.
A psychiatric technician employed since 2017 did not receive any annual performance evaluations, as required by facility policy. The HR manager and unit supervisor confirmed the absence of these evaluations, citing oversight as the reason for non-compliance.
A facility failed to document a resident's leaking G-Tube, as observed by a Psychiatric Technician after the resident returned from dialysis. Despite notifying a registered nurse, the incident was not recorded in the medical records, violating the facility's policy for documenting abnormalities in G-Tube care.
The facility failed to maintain an effective infection prevention and control program, with deficiencies involving six residents. Trash and linen carts were improperly placed outside an isolation room, and staff did not use appropriate PPE during wound care and personal hygiene activities, contrary to Enhanced Barrier Precautions guidelines. This lack of adherence to infection control policies placed residents at risk of cross-contamination and infection spread.
The facility lacked a written QAPI plan for its Skilled Nursing units, failing to identify systemic issues related to infection prevention and enhanced barrier precautions (EBP). Interviews with a Supervising RN revealed the absence of data tracking and trending, and the facility's policy on quality assurance was not followed, leading to ineffective monitoring and evaluation of patient care quality.
The facility's QAA committee failed to include the Infection Preventionist/Public Health Nurse II in its meetings, as noted in the Quality Council Minutes from two separate dates. The facility's policy did not list the Infection Preventionist as a required member, contributing to this oversight.
The facility failed to implement an effective infection control training program for all staff by not developing a written policy and training on Enhanced Barrier Precautions (EBP). Staff interviews revealed a lack of awareness and training on EBP, with admissions of not using gowns during wound care. The facility was unable to provide a policy for EBP, potentially affecting the safety and infection control among residents.
Two residents were not treated with dignity during meal times as staff stood while feeding them, contrary to facility policy requiring seated interaction. One resident was nonverbal and the other was at risk for choking, highlighting the importance of following procedures for a respectful dining experience.
The facility failed to ensure that two residents had their call lights within reach, potentially resulting in unmet needs. One resident with a history of mental health and neurocognitive disorders was observed with the call light out of reach in an enclosure bed. Another resident was repeatedly observed with the call light hanging from the wall and out of reach, despite staff acknowledging the requirement for accessibility as per facility policy.
A resident with a gastrostomy tube did not receive the prescribed amount of tube feeding due to the feeding pump being left on hold. The pump was set to deliver 60 ml per hour, but the resident only received 470 ml instead of the 660 ml ordered by the physician. This deficiency was confirmed by nursing staff and the registered dietitian.
The facility failed to ensure food safety and sanitation by having unclean, chipped, and stained food trays, expired food items in storage, a dented can improperly stored, and a marred cutting board in use. These issues were contrary to the facility's policies, which require proper cleaning, sanitization, and monitoring of food items and equipment.
The facility failed to maintain cleanliness in food storage areas, with grape juice cups, chipped wood debris, and plastic wrappers found on the floors of the warehouse and walk-in freezer. The Dietetics Director and Assistant Dietetics Director acknowledged that these areas should have been cleaned, as per the facility's policy, which requires daily sweeping and proper disposal of garbage.
A facility failed to provide a qualified interpreter for a Spanish-speaking resident, leading to communication barriers. Staff used unapproved interpreters, including other residents, to communicate with the resident, raising concerns about translation accuracy. The resident's care plans indicated the need for an interpreter, but the facility lacked a process to ensure availability each shift, despite policy requirements.
A resident, who is blind and requires moderate assistance for ambulation, fell and sustained a scalp contusion due to the facility's failure to implement fall prevention interventions. A nurse observed the resident standing unassisted but did not intervene, contrary to the resident's care plan and the facility's fall prevention policy.
A resident experienced a fall resulting in a fractured finger due to the facility's failure to implement fall prevention measures. Despite the resident's documented need for supervision and a walker, a nurse observed her walking without assistance and did not intervene. The facility's policy required registered nurses to oversee fall prevention strategies, which were not adhered to in this case.
A resident with severe cognitive impairment was assaulted by another resident with a history of behavioral disturbances, resulting in significant injuries. Despite previous incidents of aggression, no interventions were implemented for the aggressive resident, who was roomed with the vulnerable resident due to a COVID quarantine. The facility's failure to monitor and manage the aggressive resident's behavior led to the assault.
Failure to Define and Manage Resident‑to‑Resident Abuse, Leading to Unrecognized and Unreported Assaults
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement abuse policies and procedures that clearly define all forms of abuse, including resident‑to‑resident abuse, which led to multiple resident‑to‑resident physical and alleged sexual assaults not being recognized, reported, or investigated as abuse. The facility’s written abuse P&P, incident management P&P, and related training materials explicitly limited abuse definitions to acts committed by someone other than another patient, and sexual abuse to employee‑patient contact or employee‑facilitated patient contact. As a result, staff, including the Standards Compliance Director, Standards Compliance Supervising RN, Program Director, RN Shift Lead, and other nursing staff, consistently stated that resident‑to‑resident physical or sexual assaults were not considered abuse and therefore did not trigger abuse investigations, SOC 341 completion, or 2‑hour reporting to CDPH. One incident involved a resident with significant physical impairments, including absence of the left eye, a tracheostomy, a gastrostomy tube, difficulty communicating, and wheelchair dependence, who sustained a 1.2 cm laceration above the right eyebrow with bruising after being punched in the face while sleeping by another resident. The aggressor resident had schizophrenia, a criminal history of assault with force likely to produce great bodily injury, and was assessed as a moderate risk for violence against others. Staff documented that the aggressor stated he punched the other resident because the resident “tried to have sex with me,” and the injured resident reported the attack was unprovoked. Despite this, the incident was treated as a physical altercation rather than abuse, the alleged sexual component was not treated as sexual assault or abuse, no abuse investigation was conducted, and the report to CDPH was delayed until three days later because the facility did not consider resident‑to‑resident events to meet its definition of abuse. The covering psychiatrist did not evaluate either resident at the time and was unaware of the sexual abuse allegation, and there was no treatment plan or interventions in place to address the aggressor’s known aggressive behaviors or to protect other residents. A second incident involved a resident with gastrostomy status, pulmonary fibrosis, nonfunctional ambulation, and a high risk for violence against others, who kicked another resident using a front‑wheel walker in the buttocks, prompting the second resident, who had unsteadiness on feet, blindness in one eye, and a healing femur fracture with a past history of danger‑to‑others behaviors, to turn and punch the first resident in the face three times. This event was documented in the interdisciplinary notes as a physical altercation in the day hall. The facility’s leadership confirmed that resident‑to‑resident abuse was not included in the abuse P&P and that there was no separate P&P addressing protection and prevention of resident‑to‑resident abuse. The altercation was not reported to CDPH within 2 hours but instead two days later, and the resident who retaliated did not receive medication changes or enhanced monitoring after the incident, despite later having another aggressive outburst toward staff. A third incident involved two residents both assessed as moderate risk for violence against others, one with a back fracture, epilepsy, and a significant history of danger‑to‑others behaviors, and the other with a history of verbalizing thoughts of harming another resident. Staff heard yelling in the day hall and found the two residents in a verbal altercation when one resident struck the other, who reported being hit in the chin. The striking resident later stated he used a closed fist to touch the other resident’s chin to make him stop cursing and yelling. This event was also treated as a resident‑to‑resident altercation rather than abuse, resulting in delayed reporting to CDPH by two days and delayed completion of the SOC 341 until several days after the incident, instead of by the end of the shift. The psychologist later confirmed that one resident had an extensive history of verbal aggression with prior alleged physical altercations and no behavioral care plan, and that another resident’s behavioral care plan had not been updated in over a year despite aggressive incidents and stated intent to harm another resident. Across these incidents, the facility’s P&P, definitions, and staff training excluded resident‑to‑resident acts from the abuse framework, leading to failures in recognizing, preventing, investigating, protecting, and timely reporting abuse, and placing all residents at risk of unreported and unmitigated abuse. On 3/5/2026, surveyors declared an Immediate Jeopardy related to the lack of written policies and procedures prohibiting and preventing abuse that included resident‑to‑resident abuse, and to staff competency in identifying, preventing, screening, investigating, protecting, and reporting abuse under F607.
Removal Plan
- Treat physical altercations, sexual allegations, possible mental or psychological abuse, and exploitation in the SNF area as potential abuse allegations.
- Complete an SOC 341 form for each allegation of an abuse incident.
- Verify completion of SOC 341 by the RN Health Services Specialist/Supervising Registered Nurse prior to the end of the shift.
- Update reporting of unusual occurrences related to possible abuse incidents to ensure compliance with the reporting requirement.
- Program VI management/Unit Shift Lead will notify Standards immediately upon identification of a possible abuse incident to ensure reporting requirements are completed within the required timeframe.
- Program VI manager on call/unit shift lead will notify CNS for HSS to complete reporting within the required timeframe.
- Issue a written memorandum for all SNF nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting, clarifying resident-to-resident incidents must be treated as potential abuse, and including CMS SOM reference, recognition/identification, screening, prevention/protection measures, early intervention/behavioral monitoring expectations, investigation/documentation requirements, reporting requirements, and SOC 341 completion.
- Require SRN attestation that staff can verbalize understanding of the memo/education, track training via a tracking log, and provide clarification as needed to ensure staff understand the abuse screening and reporting process.
- Issue a written memorandum for all registry nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting.
- Provide training via memorandum to non-nursing clinical staff and ancillary staff on federal regulatory requirements related to abuse recognition, screening and reporting.
- Provide additional staff training regarding intervention protocols to enhance behavioral monitoring and intervention strategies for residents identified as high risk for behavioral escalation or aggression, including identification of high-risk residents, enhanced monitoring/supervision strategies, early interventions/de-escalation techniques, implementation of individualized behavioral interventions, documentation, and communication to the interdisciplinary team.
- Conduct an analysis of the physical environment, staffing, supervision, and resident assessment/care planning/monitoring to identify, correct, and intervene in situations where possible abuse, neglect, or misappropriation of resident property is more likely to occur.
- Update Administrative Directive 3308 to include resident-to-resident physical and verbal assaults, possible mental or psychological abuse, sexual allegations, and exploitation as potential abuse, including expectations for abuse screening, investigations, and reporting requirements.
- Conduct an ongoing review of all incident reports involving resident-to-resident altercations or allegations to ensure SOC 341 reports are completed and reporting timelines are met.
Failure to Protect Resident From Assault by Known Violent Peer
Penalty
Summary
The deficiency involves the facility’s failure to protect a medically fragile resident from physical abuse by another resident who had been previously identified as a moderate risk for violence against others. Resident 1’s MDS showed he had an absence of the left eye, a tracheostomy, a gastrostomy tube, difficulty communicating needs, and required a wheelchair for ambulation. On observation, Resident 1 was seen in bed with a noticeable laceration and bruising above the right eyebrow, and he reported that another resident attacked him in his sleep without provocation. A nurse later observed dried blood above Resident 1’s eyebrow, and Resident 1 again reported that he had been punched in the face while sleeping. Resident 2’s treatment plan documented diagnoses including schizophrenia and a criminal history of assault by means of force likely to produce great bodily injury, and an evaluation on 1/22/2026 identified Resident 2 as a moderate risk for violence against others. Staff interviews indicated that Resident 2’s medical condition had improved to the point that he was highly ambulatory and no longer medically fragile. The Registered Nurse Shift Lead stated she was not surprised by the incident because Resident 2 had attempted to punch a staff member in October 2025, and a prior recommendation from the state hospital indicated Resident 2 should be carefully monitored due to a demonstrated history of violent behaviors. Despite these known risks, Resident 2 was able to access Resident 1’s room and punch him in the face while he slept. Subsequent documentation and interviews confirmed Resident 2’s aggressive behavior and intent. During an interview, Resident 2 admitted punching Resident 1 and stated he did so because he believed Resident 1 wanted to have sex with him. Physician progress notes recorded that Resident 2 told staff he was hearing voices to hurt others, that he had attacked a peer and caused injury, and that he would continue hitting people until he was discharged. The facility’s policies on reporting abuse and on treatment planning required that abuse not be tolerated and that treatment plans address individualized risks, including danger to others, and that mini-team conferences be held after episodes of aggression. The failure to implement adequate supervision, environmental interventions, and behavioral interventions for Resident 2, despite documented risk factors and prior aggressive behavior, led to Resident 1 being physically assaulted and injured while asleep.
Failure to Train Staff on Recognition and Reporting of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure all staff received adequate training on the recognition, prevention, and reporting of all forms of abuse, including resident-to-resident abuse, as required by Federal regulations. Surveyors reviewed an interdisciplinary note for one resident dated 2/7/2026, which documented that this resident was punched in the face by another resident, resulting in a 1.2 cm laceration to the right upper eyebrow that required medical attention. The note further documented that the resident who did the punching told staff, “I punched him early in the morning because he tried to have sex with me,” indicating an alleged attempted sexual contact and a physical assault between residents. During interviews, multiple staff members demonstrated that they did not recognize resident-to-resident physical or sexual incidents as abuse. One RN stated he received annual abuse training that covered only staff-to-resident abuse, reporting, and prevention. Another RN described finding dried blood above a resident’s right eyebrow, being told by that resident that another resident had punched him while he was sleeping, and then being told by the alleged aggressor that he hit the resident because the resident wanted to have sex with him. This RN characterized the incident as a physical altercation rather than abuse and did not consider the allegation of attempted sexual contact to be sexual assault or abuse, despite confirming he had received annual abuse training. Additional interviews with the Registered Nurse Shift Lead, the Program Director, and the Nursing Coordinator showed a consistent belief that only staff-to-resident physical or sexual assault constituted abuse and that residents could not be perpetrators of abuse. Review of the facility’s abuse training materials and policies showed that the definitions of physical, psychological, verbal, and sexual abuse were limited to actions by “someone other than another patient,” and sexual abuse was defined in terms of employee conduct or employee allowance of sexual contact between patients. These policy definitions and training content excluded resident-to-resident abuse, contributing directly to staff’s inability to recognize and report the resident-to-resident physical and alleged sexual assault as abuse for two sampled residents.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to identify and report resident-to-resident physical and sexual abuse allegations within the required timeframe for three separate incidents. In the first incident, one resident punched another in the face, causing a laceration above the right eyebrow, after alleging that the other resident attempted to engage in unwanted sexual activity. The Standards Compliance Supervising RN confirmed the incident and the sexual assault allegation but stated that the department of standards and compliance was not open over the weekend and that she did not consider resident-on-resident physical and/or sexual assault as abuse, so it was not reported within 2 hours. The facility’s own policy, however, defined abuse of a dependent adult/elder to include physical abuse and sexual assault and required all alleged violations involving abuse in skilled nursing units to be reported to CDPH immediately, but not later than 2 hours after the allegation. The Patients’ Rights Advocate (PRA) also reported not receiving any notification of physical and/or sexual assault or abuse related to this incident. In the second incident, one resident kicked another in the buttocks without provocation, and the second resident retaliated by punching the first resident in the face three times. The Standards Compliance Director confirmed that this physical altercation was not reported to CDPH until two days after it occurred, despite the policy requiring reporting within 2 hours, and the PRA stated he had not received any notification of physical abuse for either resident. In the third incident, a resident allegedly punched another resident in the chin following a verbal altercation; the Standards Compliance Director again confirmed that this allegation was not reported to CDPH until two days after the incident, and the PRA reported no notification of this physical abuse allegation. Across all three events, the facility did not follow its policy requiring immediate, but no later than 2-hour, reporting of all alleged abuse to CDPH and failed to notify the PRA of the allegations.
Failure to Investigate and Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to treat resident-to-resident physical and sexual assault allegations as abuse, to conduct thorough investigations, and to report results to the State Survey Agency within required timeframes. One resident with schizophrenia (Resident 2) alleged that another resident (Resident 1) tried to have sex with him, and also admitted to punching that resident in the face. Interdisciplinary notes dated 2/7/2026 documented that Resident 1 sustained a 1.2 cm laceration to the right upper eyebrow requiring medical attention after being punched by Resident 2. Standards Compliance Supervising RN confirmed that these incidents were not considered abuse by the facility because they involved resident-to-resident physical and sexual assault, and therefore were not reported to the California Department of Public Health (CDPH) within 2 hours; instead, they were reported three days later. The facility did not conduct a thorough investigation into the alleged sexual assault. RN 2 stated he interviewed Resident 2, who reported he hit Resident 1 because he was trying to have sex with me, but RN 2 did not ask any further questions. The Program Director reported that after speaking with nursing staff and the treatment team, they concluded there was no validity to the sexual assault allegation and determined it was a delusion, and therefore did not investigate it as abuse or complete a SOC 341 suspected abuse report. Resident 2’s medical record did not contain a physician report following the sexual assault allegation, and the temporarily assigned psychiatrist did not see or evaluate Resident 2 until three days after the incident and did not address the allegation. The on-call psychiatrist on the date of the incident did not go to the unit to evaluate Resident 2 after the allegation, and the Patients’ Rights Advocate was not notified of the allegation. The facility also failed to investigate the physical assault on Resident 1 as abuse and to follow its own abuse reporting policies. Resident 1, who had multiple complex medical conditions including absence of the left eye, a tracheostomy, a gastrostomy tube, need for assistance, difficulty communicating needs, and use of a wheelchair for ambulation, was punched in the face by Resident 2 while sleeping, resulting in a laceration requiring medical attention. The Program Director stated that resident-on-resident physical assault was not considered abuse and that only staff could be perpetrators, so the incident was not investigated as abuse and a SOC 341 was not completed. The psychiatrist who saw Resident 1 four days after the incident focused only on medical issues related to the tracheostomy and did not address the physical assault. The Patients’ Rights Advocate was not notified of the physical assault, and the on-call psychiatrist did not evaluate either resident after being informed of the incident. These actions and inactions occurred despite facility policies defining physical abuse as including assault and requiring immediate completion of SOC 341, protection and counseling for the resident, notification of the Patients’ Rights Advocate, immediate reporting of alleged abuse to CDPH within 2 hours, and submission of investigation results to CDPH within 5 working days. The facility’s written policies on rape or sexual assault of elder/dependent adults and on reporting patient abuse and neglect required immediate medical attention, supportive counseling, evidence gathering, completion of SOC 341, physician reporting, and prompt reporting to CDPH for all alleged abuse, including in skilled nursing units. The policies also required that all alleged violations involving abuse be reported immediately but not later than 2 hours if the events involved abuse, and that results of investigations or follow-up reports be submitted to CDPH within 5 working days. In the incidents involving Residents 1 and 2, the facility did not follow these policies: alleged sexual assault and physical assault were not treated as abuse, SOC 341 forms were not completed, the Patients’ Rights Advocate was not notified, physician evaluations and reports were delayed or omitted, and the results of investigations were not submitted to the State Survey Agency within 5 working days because investigations were not conducted.
Failure to Ensure Enclosure Bed Safety Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of neurocognitive disorder, epileptic seizures, and traumatic brain injury, who was identified as high risk for falls, experienced a fall from an enclosure bed. The enclosure bed, designed with mesh walls and a zipper to prevent falls, failed to provide adequate protection when the net zipper malfunctioned or was not properly secured. Staff had previously observed the resident inspecting and attempting to manipulate the zipper while inside the bed. On the day of the incident, the resident was found on the floor after managing to open the zipper, either due to a malfunction or because it was not properly secured by staff. Record reviews and staff interviews revealed that the resident was on 15-minute supervision for safety at the time of the unwitnessed fall. Facility policy required nursing staff to ensure all zippers were secure and clipped during rounds, whether the bed was occupied or unoccupied. However, staff did not ensure the enclosure bed was properly secured or in good working condition, which contributed to the resident's ability to open the bed and fall.
Failure to Timely Report Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure for reporting allegations of abuse when a resident with schizoaffective disorder, bipolar type, disclosed to a psychologist that they had been beaten and raped. The psychologist documented the disclosure in a progress note but did not report the allegation to her supervisor, program management, or standards and compliance, nor did she complete the required incident report or SOC 341 form. The psychologist believed that abuse occurring in a different facility did not require reporting, despite facility policy stating that all allegations, regardless of when or where they occurred, must be reported if not previously documented. Interviews with facility staff, including the Standards and Compliance officer, Psychologist Director, Unit Supervisor, and Program Director, confirmed that no incident report was filed, and the required notifications to the state survey agency and other authorities were not made. The facility's policies clearly require immediate reporting and documentation of all abuse allegations, including those reported to have occurred prior to admission or in other facilities, but these procedures were not followed in this case.
Failure to Complete Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for a psychiatric technician who had been employed since November 2017, resulting in eight missed evaluations. During a review of the employee's file, it was confirmed by the Staff Services Manager HR that no performance evaluations had been conducted, despite facility policy requiring annual appraisals. The Unit Supervisor acknowledged that she had not completed any evaluations for the employee, attributing the omission to oversight. The facility's policy and procedure document specified that supervisors and managers are responsible for preparing annual performance appraisal summaries for their assigned employees.
Failure to Document G-Tube Leakage
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for a resident with a leaking Gastrostomy-tube (G-Tube). The resident, who had a history of schizophrenia, end-stage renal disease, essential hypertension, heart failure, and type 2 diabetes mellitus, was admitted to the facility and required a G-Tube for nutrition. On a specific date, a Psychiatric Technician (PT) observed that the resident's G-Tube dressing was saturated with clear liquid, and the abdominal binder was wet after the resident returned from dialysis. The PT notified the registered nurse about the situation but did not document the assessment in the treatment record. During a review of the resident's medical records, it was confirmed that there was no documentation of the leaking G-Tube in the Interdisciplinary Note (IDN) or the Medication and Treatment Record. The facility's policy and procedure for enteral tubes required that any abnormalities or refusals discovered during G-Tube care should be documented in an IDN. However, the Registered Nurse Mentor (RNM) confirmed that no such documentation was present in the resident's medical record, indicating a failure to adhere to the facility's documentation policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies involving six residents. For Resident 7, trash and linen carts were improperly placed outside the isolation room, contrary to the facility's policy that requires these carts to be inside the room to contain infection. Additionally, a psychiatric technician accepted a water pitcher from Resident 7, who was on isolation precautions, without wearing gloves, risking the transmission of influenza. In the case of Resident 36, a registered nurse and a psychiatric technician performed wound care using only gloves and masks, without the required gowns, despite the resident having unstageable pressure injuries. This was a breach of the Enhanced Barrier Precautions (EBP) guidelines, which mandate gown and glove use during high-contact care activities for residents with wounds. Similarly, Resident 1 received wound care without the use of a gown, and the staff involved were unaware of the EBP guidelines, indicating a lack of training and policy implementation. Further deficiencies were noted with Residents 35, 11, and 54, where staff failed to wear gowns during personal hygiene and dressing changes, despite the presence of conditions such as MRSA colonization and pressure injuries. The facility's policies and procedures were not followed, and there was a lack of awareness and training regarding EBP among the staff, contributing to the risk of cross-contamination and the spread of infections.
Lack of QAPI Plan in Skilled Nursing Units
Penalty
Summary
The facility failed to have a written Quality Assurance Performance Improvement (QAPI) plan in place for the Skilled Nursing units, which is essential for evaluating and improving the quality of resident care and services. During interviews with the Supervising Registered Nurse (SRN) 3, it was revealed that there was no existing QAPI plan, and the facility was not actively tracking or trending data related to the program and residents. This lack of a structured QAPI plan resulted in the facility's inability to identify systemic problems, particularly concerning infection prevention and enhanced barrier precautions (EBP). The facility's policy and procedure document, titled 'Quality Assurance' and dated 5/3/24, outlined the purpose of the Quality Assurance Program as establishing a systemic process to monitor and evaluate patient care quality. However, the facility did not adhere to this policy, as evidenced by the absence of a QAPI plan and the failure to discuss EBP during QAPI activities. This deficiency highlights the facility's inability to implement and report on activities and mechanisms for monitoring and evaluating the quality of patient care, as required by the governing body.
QAA Committee Lacks Required Infection Preventionist Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee had the required members in attendance, specifically the Infection Preventionist/Public Health Nurse II for the Skilled Nursing unit. This was identified during a concurrent interview and record review with the Standards Compliance Director (SCD) on November 8, 2024, where the SCD acknowledged the absence of the Infection Preventionist in the Quality Council Minutes from the September 5, 2024 meeting. Additionally, a review of the Quality Council Minutes from April 23, 2024, also indicated the absence of the Infection Preventionist. The facility's Policy and Procedure titled 'Risk Management,' dated July 8, 2024, did not list the Infection Preventionist as a required member of the Quality Council under section 4.3.1, which contributed to this oversight.
Lack of EBP Training and Policy in Facility
Penalty
Summary
The facility failed to maintain an effective infection control training program for all 94 staff members by not developing a written policy and training regarding Enhanced Barrier Precautions (EBP). EBP involves the use of gowns and gloves during high-contact resident care activities to reduce the spread of infections. During an observation, it was noted that there was no personal protective equipment (PPE) cart or EBP signage by the door of a resident's room who had unstageable pressure injuries. Interviews with various staff members, including the Interim Infection Preventionist, Registered Nurse, Psychiatric Technician, RN Shift Lead, Supervising RN, and Nursing Coordinator, revealed a lack of awareness and training on EBP. The staff admitted to not using gowns during wound care and were unaware of the EBP guidelines. The facility was unable to provide a policy for EBP upon review, and staff interviews confirmed that no training had been conducted. The Interim Infection Preventionist and other staff members acknowledged that they were not up to date with EBP and that the facility's policy did not address it. The lack of training and policy on EBP had the potential to negatively affect the facility's ability to maintain a safe environment and prevent the spread of infectious diseases among the 54 residents in the facility.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during meal times for two residents. In the first instance, a registered nurse (RN) was observed standing while feeding a nonverbal resident in bed, which did not allow for eye-level interaction. The RN acknowledged that standing over the resident could be intimidating and affect the resident's dignity. The facility's policy required staff to be seated and attentive when feeding residents, which was not followed in this case. In the second instance, another RN was observed standing while assisting a resident with drinking in the dining room. This resident was at risk for choking, and the RN admitted that he should have been seated while assisting the resident. The facility's policy also required staff to remain seated and attentive when feeding residents, which was not adhered to. Both instances highlight a failure to provide a respectful and dignified dining experience as per the facility's established procedures.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, which could potentially result in unmet needs. Resident 357, who has a history of schizoaffective disorder, bipolar type, and major neurocognitive disorder due to traumatic brain injury, was observed in an enclosure bed with the call light dangling outside and out of reach. During interviews, both a Psychiatric Technician and a Registered Nurse acknowledged that the call light should have been accessible to the resident, as per the resident's care plan and the facility's policy and procedure on call light use. Similarly, Resident 26 was observed multiple times with the call light hanging from the wall and out of reach. A Registered Nurse confirmed that the call light should have been within reach, and a Supervising Registered Nurse stated that rounds were conducted every 30 minutes to ensure resident safety, including the accessibility of call lights. Despite these procedures, the call light was repeatedly found out of reach during observations, indicating a failure to adhere to the facility's policy and procedure on call light use.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to provide tube feeding according to the doctor's order for a resident with a gastrostomy tube (GT). During an observation, the resident's tube feeding pump was found alarming and not delivering the prescribed nutrition. The feeding pump was set to deliver 60 milliliters of liquid nutrition per hour, but the pump was left on hold after patient care, resulting in the resident not receiving the correct amount of tube feeding. The registered nurse shift lead confirmed the pump was not infusing and was unaware of the duration or the amount of feeding missed. Further interviews revealed that the resident received only 470 milliliters of tube feeding instead of the 660 milliliters ordered by the physician. The registered dietitian confirmed that not receiving the ordered tube feeding could lead to weight loss for the resident. The physician's orders indicated the resident should receive tube feeding at a rate of 60 milliliters per hour for 22 hours via the GT, but this was not adhered to, leading to a deficiency in care.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to meet food service safety and sanitation requirements, as observed during a survey. In the clean tray area, 15 food trays were found to be unclean, chipped, and stained with brown and yellowish marks, with one tray still having an old meal ticket attached. This was contrary to the facility's policy, which mandates that all kitchen and dining room utensils, along with food contact surfaces, be cleaned and sanitized before use, after use, and after each meal. Additionally, expired food items, including a pack of sugar and 16 boxes of coleslaw, were found in the dry warehouse and food storage area, respectively. The facility's policy requires staff to observe all food item expiration dates to ensure no expired products are used or stored. Further deficiencies were noted in the dry warehouse, where a dented can of vanilla pudding was improperly stored on a rack labeled 'use it first' instead of being placed in the designated Dented Cans Area. The facility's policy states that any damaged or dented cans should be rejected at the point of delivery. In the cold prep area, a yellow cutting board was found to be heavily marred with deep cut marks, which could harbor bacterial growth. This was inconsistent with the facility's policy that requires all food contact surfaces to be cleaned and sanitized before and after use.
Improper Disposal of Garbage and Debris in Food Storage Areas
Penalty
Summary
The facility failed to maintain cleanliness in food storage areas, specifically in the warehouse and main kitchen, which could potentially lead to foodborne illness among residents. During an observation and interview with the Dietetics Director (DD), two cups of grape juice and chipped wood debris were found on the warehouse floor. The DD disposed of the grape juice cups and acknowledged that the trash and debris should have been cleaned. Similarly, during an observation with the Assistant Dietetics Director (ADD) in the walk-in freezer, chipped wood and plastic wrappers were observed on the floor, and the ADD confirmed that these should have been cleaned. The facility's Policy and Procedure, titled Nutrition Policy Manual Policy Number: 3401, dated July 2018, states that garbage should always be placed in designated disposal units with lids, and storerooms should be swept daily to remove debris from deliveries or daily activities. The failure to adhere to these procedures was noted during the survey.
Failure to Provide Qualified Interpreter for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide a qualified, facility-approved interpreter for a Spanish-speaking resident, resulting in communication barriers. During an observation and interview, it was noted that the resident was unable to communicate effectively with staff due to the lack of a Spanish-speaking interpreter. The Lead Registered Nurse admitted to using non-approved interpreters, including other residents, to communicate with the resident. This issue was further highlighted when a medical evaluation was conducted using an unapproved interpreter, raising concerns about the accuracy of the translation and the resident's ability to convey his needs and concerns. The resident's care plans and assessments clearly indicated the need for a Spanish-speaking interpreter, yet the facility did not have a process to ensure interpreters were available each shift. Interviews with staff, including a Supervising Registered Nurse and a Social Worker, confirmed the absence of a reliable system for providing interpreters, leading to reliance on unapproved staff for translation. This deficiency was compounded by the facility's policy, which stated that accommodations should be made for non-English speaking patients, yet failed to implement a practical solution to meet this requirement.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident, resulting in a fall and a scalp contusion. During an observation and interview, the resident was found with discoloration on the left side of his forehead and reported not using his wheelchair when standing, which led to a fall. The resident, who is blind and requires moderate assistance for ambulation and transfers, experienced pain and nausea following the incident. A registered nurse observed the resident standing unassisted from his wheelchair and falling forward but did not intervene or educate the resident to sit down. The resident's care plan indicated the need for moderate assistance and education to prevent unassisted transfers. The facility's policy on fall prevention requires registered nurses to implement and oversee fall prevention strategies, which were not followed in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident, resulting in a fracture to the resident's left fifth finger. During an observation and interview, the resident revealed that she did not use her walker while ambulating, which led to her fall and subsequent injury. The resident's Minimum Data Set indicated that she required supervision or assistance when ambulating, and her treatment plan highlighted her unsteadiness and risk for falls, specifying the need for a walker and staff assistance. Despite these documented needs, a registered nurse observed the resident walking without her walker and did not intervene or educate her to use it. The supervising registered nurse confirmed that the resident should have been stopped and reminded to use her walker. The facility's policy on fall prevention emphasized the responsibility of registered nurses to implement fall prevention strategies, which were not followed in this instance, leading to the resident's fall and injury.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in significant injuries. Resident 1, who was non-verbal, medically compromised, and bedridden, was assaulted by Resident 2, who had a history of major neurocognitive disorder with behavioral disturbances. Resident 1 sustained multiple facial lacerations, contusions, and a nasal bone fracture due to the assault. The incident was unwitnessed, but Resident 2 was found with bloodied hands and blanket, and Resident 1 was transferred to the hospital for evaluation. Resident 2 had a documented history of impulsivity, low frustration tolerance, and dangerousness to others, with previous incidents of aggression towards peers. Despite this, no interventions were implemented following a prior altercation with another resident, and Resident 2 was roomed with Resident 1 due to a COVID quarantine on the unit. The facility's treatment plan for Resident 2 noted a moderate violence risk factor, but lacked documented interventions related to dangerousness and impulsivity. Interviews with facility staff revealed that Resident 2's behaviors were unpredictable, and no PRN medication or increased observation was ordered after the incident. The facility's policy on reporting patient abuse and neglect clearly stated that abuse is not tolerated, yet the lack of appropriate interventions and monitoring for Resident 2 contributed to the failure to protect Resident 1 from harm.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Norwalk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottage Crest Post Acute | 1.8 mi | — | 4 | 0 |
| Norwalk Skilled Nursing & Wellness Centre, Llc | 1.9 mi | — | 1 | 0 |
| Southland | 2.3 mi | — | 7 | 0 |
| Intercommunity Healthcare & Rehabilitation Center | 2.4 mi | — | 3 | 0 |
| Studebaker Healthcare Center | 2.5 mi | — | 46 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.