Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Marlora Post Acute Rehab Hosp during CMS and state inspections, most recent first.
A resident with ESRD, DM, and significant psychiatric and behavioral issues was transferred to another SNF without the facility providing the completed Discharge Summary/Post Discharge Plan of Care to the receiving facility. Although a detailed discharge plan had been initiated, including PCP follow-up, HD schedule and transportation, monitoring of VS, one-on-one supervision, safety needs, blood sugar checks, ADL assistance, and anemia treatment information, the RN Supervisor only sent a face sheet with a transfer report/medication list, along with medications and belongings. The RN Supervisor believed the Discharge Planner had already sent the discharge summary, and no telephone report to licensed staff at the receiving facility was documented, contrary to facility policies requiring transfer/discharge documentation and communication of the discharge summary.
The facility did not notify CDPH within 24 hours after two residents and a staff member tested positive for COVID-19, despite guidance from the PHN and internal policy requiring prompt reporting of such outbreaks. The delay occurred because the IPN believed that reporting to the local public health office was sufficient, resulting in CDPH not being informed in a timely manner.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Two residents who required assistance with ADLs and had intact cognition were not provided with care plans addressing their assessed needs for smoking safety measures, such as smoking aprons and a cigarette extension. Both were observed smoking without the required equipment, and staff confirmed that no care plans were in place to guide interventions, contrary to facility policy.
Two residents received pain medication outside the prescribed pain level parameters, with staff administering narcotics when pain was documented as 0 or 3, contrary to physician orders specifying administration only for pain levels of 4-10. Staff interviews and record reviews confirmed that these actions did not align with facility policy or prescriber instructions.
A resident with a history of falls, cognitive impairment, and mobility issues was not provided with a comprehensive, individualized fall care plan. The care plan lacked specific interventions for the resident's non-compliance with call light use and did not address ongoing risks, resulting in an unwitnessed fall after the resident attempted to use the restroom independently.
The facility failed to ensure residents were free from significant medication errors, affecting four out of eight sampled residents. A resident did not have their heart rate checked before receiving Amiodarone, and another resident missed doses of Mexiletine, with late doses administered at incorrect intervals. The facility did not monitor for adverse effects or communicate effectively between shifts. Additionally, residents received medications without proper vital sign checks, and the facility's policies on medication administration and error documentation were not followed.
The facility's QAA and QAPI committees failed to identify significant medication errors, such as missed doses and late administration, due to a lack of focus on these issues in their current QAPI plan. The DON was unaware of these errors until surveyors identified deficiencies. The facility's policies required medication errors to be documented and reviewed by the QAPI committee, but this was not effectively implemented, placing residents at risk.
The facility failed to provide mandatory training in effective communication for two LVNs upon hire. A review of their personnel records showed no evidence of such training, and the DSD confirmed its absence from orientation. The DON acknowledged the need for mandatory training, as the facility's policy requires nursing staff to meet competency requirements, including communication skills.
The facility failed to provide mandatory QAPI training to two newly hired LVNs, as revealed during a review of their personnel records. The Director of Staff Development confirmed that QAPI training was not part of the orientation services, and the Director of Nursing acknowledged the need for such training. The facility's policy requires all nursing staff to meet competency requirements defined by state law.
The facility failed to update the Advance Directives (AD) for two residents, leading to potential conflicts with their healthcare wishes. One resident, with mental health diagnoses, signed an invalid AD form due to cognitive impairment. Another resident had an AD but the facility lacked a copy. The facility's policy requires AD information upon admission, which was not followed.
Two residents experienced significant medical events that were not promptly communicated to their physicians. A resident with diabetes had a critically high blood sugar level, and another resident missed or received late doses of a critical heart medication. The facility failed to notify the physicians as required by policy, leading to potential delays in medical intervention.
The facility failed to protect residents from abuse and neglect, resulting in significant deficiencies. A resident with end-stage renal disease was allegedly sexually assaulted by another resident, and the facility did not take adequate measures to ensure safety or monitor the situation. In another incident, an agitated resident with dementia was placed near others, leading to a physical altercation with another resident. The facility's failure to follow policies and procedures contributed to these deficiencies.
The facility failed to report a physical altercation between two residents to the CDPH within the required two-hour timeframe. One resident, with dementia and major depressive disorder, hit another resident, with major depressive disorder and PTSD, using a quad cane. Although the incident was reported to local authorities, it was not reported to CDPH as mandated by the facility's policy.
The facility failed to report allegations of physical abuse involving two residents to CDPH within the required timeframe. An altercation occurred when a resident with moderately impaired cognitive skills hit another resident with a quad cane. The incident was reported to local authorities but not to CDPH, violating the facility's policy on abuse investigation and reporting.
The facility failed to provide trauma-informed care for two residents with PTSD, as they did not assess triggers or develop care plans to prevent re-traumatization. Despite having policies in place, the facility did not implement guidelines to address the residents' trauma histories, leading to a deficiency in care.
The facility failed to ensure competent medication administration by nurses, resulting in significant errors for several residents. A resident with severe cognitive impairment received medication without proper pulse checks, while another with cardiac issues had medications administered at incorrect times and without necessary vital sign documentation. Additionally, a resident with hypotension received medication despite high blood pressure readings, and another with heart failure had medications given without proper monitoring. Interviews revealed that nurses were not adhering to facility policies, leading to these errors.
A facility failed to conduct an IDT meeting for a resident after multiple eye doctor appointments, resulting in a lack of awareness about the outcomes and necessary care adjustments. The resident, with conditions like ESRD and diabetes, experienced vision decline but had no IDT meeting since June, despite policy requirements for meetings upon significant changes. Staff interviews confirmed the oversight, acknowledging the need for a meeting to address the resident's care plan.
A resident with multiple health issues, including declining vision, did not have a care plan addressing his vision concerns, despite ongoing eye doctor visits and the resident's awareness of needing surgery. The facility's staff, including an LVN and the MDS Nurse, confirmed the absence of a care plan, which was against the facility's policy requiring timely and comprehensive care planning.
A resident received diclofenac sodium gel without a specified dose for over two weeks, posing a risk of incorrect dosing. The resident had serious heart conditions and impaired cognitive skills. The LVN and DON acknowledged the need for dose specification, which was not included in the medication order, contrary to the facility's policy.
A resident with a history of urinary issues and frequent UTIs did not receive consistent foley catheter care as per the facility's orders, leading to potential recurrent UTIs. The Treatment Administration Record showed missing documentation for catheter care on several dates, and interviews with staff confirmed that undocumented care was likely not provided. The facility's policy required regular catheter care and monitoring to prevent infections, but gaps in documentation indicated non-compliance.
A resident with chronic lung conditions was found to be receiving 2.5 liters per minute of oxygen instead of the prescribed 2 liters per minute. This discrepancy was confirmed by the ADON, who acknowledged the importance of following the physician's order for safe oxygen administration. The DON reiterated the need for staff to adhere to prescribed orders to ensure resident safety.
A facility failed to monitor a resident's behaviors while on psychotropic medications, risking unnecessary medication use. The resident, with dementia and other conditions, was on Escitalopram and Mirtazapine, but there was no documentation of monitoring for hopelessness, anxiety, or sleep. Staff interviews confirmed the facility did not adhere to its policy for behavioral assessment and monitoring.
A medication security lapse occurred when an LVN left a resident's Amiodarone unattended on a medication cart. The resident, with severe cognitive impairment and serious cardiac conditions, was at risk due to this oversight. The facility's policy mandates that medications be accessible only to authorized personnel.
A facility failed to sanitize a mechanical lift between uses for two residents, potentially spreading infections. CNA 1 and CNA 2 used the lift for a resident with end-stage renal disease and then for another resident with chronic kidney disease without cleaning it. CNA 1 admitted to forgetting the cleaning step, and the Director of Staff Development emphasized the importance of sanitizing equipment to prevent infection spread.
A resident at an LTC facility fell and sustained a right shoulder fracture due to a CNA's failure to follow the facility's policy requiring two-person assistance during a Mechanical Lift transfer. The resident, who was high risk for falls and dependent on staff for transfers, was injured when the CNA attempted the transfer alone. Staff interviews confirmed the policy requirement for two-person assistance, which was not followed, leading to the incident.
Two residents experienced violations of their rights and dignity in a LTC facility. One resident, with anxiety and depression, was disrespected by the ADM and BOM during a financial discussion in his room without permission. Another resident, with anxiety and schizophrenia, was moved to a new room against her wishes to accommodate new admissions. The ADM's actions did not align with facility policies on resident rights and dignity.
A resident with dysphagia experienced a choking incident, and the facility staff delayed calling 911 by 14 minutes while checking the resident's code status. The staff also failed to use a non-rebreather mask and did not retrieve the crash cart, leading to inadequate emergency care. Interviews revealed poor communication and delegation among staff during the incident.
A resident with dysphagia choked on noodles during dinner, requiring an LVN to perform the Heimlich maneuver. The LVN failed to document the incident and care provided, resulting in an incomplete medical record. This oversight hindered communication between healthcare professionals and the facility's ability to investigate the incident.
A resident's grievance about missing personal belongings, including a cellphone, was not resolved to their satisfaction. Despite the cellphone being inventoried, the facility did not replace or reimburse it, and the resident's representative was dissatisfied with the response. The facility's policy required prompt resolution of grievances, but this was not achieved.
A resident with cognitive impairment and multiple diagnoses pulled out his Foley catheter, causing moderate bleeding. The facility notified the physician promptly but delayed informing the family for five hours, leading to family dissatisfaction. The ADON acknowledged the delay and the facility's policy requires prompt notification of any change in condition.
Failure to Send Complete Discharge Summary to Receiving SNF
Penalty
Summary
The deficiency involves the facility’s failure to provide a complete Discharge Summary/Post Discharge Plan of Care to the receiving SNF when a resident was transferred. The resident had multiple significant diagnoses, including ESRD, DM, schizophrenia, depression, and anxiety disorder, and had been assessed as unable to make reasonable and consistent decisions or understand and make medical decisions. Prior documentation showed the resident had exhibited severe behavioral issues, including banging hands on the wall and attempting to grab staff members’ private parts, which led to a psychiatric hold and subsequent readmission. An IDT care conference documented that discharge options to a more appropriate SNF capable of managing the resident’s behavioral needs were discussed with the responsible party. On the day of transfer, a physician’s order directed that the resident be transferred to another SNF with all remaining medications, and that a representative from the receiving facility would pick up the resident’s medications, belongings, and discharge paperwork. Nursing progress notes documented that the RN Supervisor was unable to reach licensed staff at the receiving facility despite multiple calls, but that a representative from the receiving facility would pick up the resident’s medications, cigarettes, and belongings. The facility had initiated a Discharge Summary/Post Discharge Plan of Care the day before transfer, which included instructions to follow up with the primary care physician, details of the hemodialysis facility, treatment schedule and transportation, monitoring of vital signs and overall well-being, one-on-one supervision and safety needs, blood sugar checks, assistance with ADLs, and the latest hemoglobin result with associated anemia treatment. Despite this, the RN Supervisor provided only the face sheet with the transfer discharge report/transfer medication list, along with the resident’s belongings and medications, to the receiving facility’s representative and did not print or send the Discharge Summary Instructions. The RN Supervisor stated he believed the Discharge Planner had already sent the discharge summary to the receiving facility and that he was told only to send the transfer medication list, medications, and belongings. The responsible party later reported that the receiving SNF could not provide discharge instructions from the sending facility. Review of facility policies titled “Transfer or Discharge Documentation” and “Discharging the Resident” showed that the facility’s procedures required that a copy of the resident’s discharge summary and other appropriate documentation be communicated to the receiving facility and that a transfer summary and telephone report be completed, which did not occur in this case.
Failure to Timely Report COVID-19 Outbreak to CDPH
Penalty
Summary
The facility failed to notify the California Department of Public Health (CDPH) within 24 hours after identifying a COVID-19 outbreak involving two residents and one staff member. Record reviews showed that one resident, admitted with Parkinson's disease and failure to thrive, exhibited symptoms such as dizziness, sore throat, and runny nose and tested positive for COVID-19. Another resident, admitted with hypothyroidism, tested positive for COVID-19 but was asymptomatic. Both cases were identified on the same day, and a staff member also tested positive the following day. Despite receiving guidance from the Public Health Nurse (PHN) to report the outbreak to CDPH, the facility's Infection Preventionist Nurse (IPN) delayed reporting, believing that notifying the local public health office would suffice. Interviews with facility leadership confirmed awareness of the reporting requirement and the PHN's guidance. The IPN and Administrator acknowledged that the outbreak met the criteria for an unusual occurrence and should have been reported to CDPH within 24 hours, as outlined in the facility's policy. The delay in reporting resulted in CDPH not being informed in a timely manner, which prevented oversight and monitoring of the facility's infection control practices during the outbreak.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Develop and Implement Smoking-Related Care Plans
Penalty
Summary
The facility failed to develop and implement care plans addressing the smoking needs of two residents who required substantial or maximal assistance with activities of daily living and had intact cognition. Both residents had documented assessments indicating the need for specific safety measures while smoking, such as the use of a smoking apron and, for one resident, a cigarette extension. Despite these documented needs, there were no care plans created to guide staff in providing the necessary interventions to ensure the residents' safety during smoking activities. Observations revealed that both residents were seen smoking without the required safety equipment, and staff confirmed that no care plans were in place for smoking-related risks. Interviews with nursing staff and the DON confirmed the absence of care plans and acknowledged that care plans are intended to guide staff in maintaining resident safety. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not followed for the two residents in question.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed by the physician for two out of four sampled residents. For one resident with diagnoses including metabolic encephalopathy and mood disorder, the physician's order specified that Oxycodone-Acetaminophen should be given only for breakthrough pain rated 4-10 out of 10. However, the Medication Administration Record (MAR) showed that the medication was administered when the resident's pain level was documented as 0 and 3, which did not meet the criteria outlined in the physician's order. Interviews with nursing staff confirmed that the medication was given outside the prescribed parameters, and staff acknowledged that this was not in accordance with the order. Another resident, admitted with diagnoses such as encephalopathy, sciatica, and dementia, had a physician's order for Hydrocodone-Acetaminophen to be administered for moderate to severe pain (pain level 4-10). The MAR indicated that this resident also received pain medication when their pain level was documented as 0. Staff interviews confirmed that the medication should not have been administered at a pain level of 0, and that the documentation was inaccurate. The facility's policy on administering medications requires that medications be given in accordance with prescriber orders, including any specified parameters. The observed practice of administering pain medication outside the prescribed pain levels for both residents was not consistent with these requirements, as confirmed by staff interviews and record reviews.
Failure to Develop and Implement Comprehensive Fall Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, resident-centered fall care plan for a resident with a history of falls, encephalopathy, sciatica, and dementia. The resident was assessed as having mildly impaired cognitive skills and required moderate assistance with several activities of daily living, including transfers and toileting. Despite being identified as a fall risk due to balance problems, history of multiple falls, and other medical conditions, the care plan only included an intervention to place the resident in a room near the nursing station for better visibility. The resident experienced an unwitnessed fall after not using the call light to request assistance with a restroom transfer. Interviews with staff revealed that the resident often attempted to go to the bathroom independently and did not consistently use the call light, despite reminders and reeducation. Staff also noted the resident's desire for independence, forgetfulness, unsteady gait, and occasional non-compliance with safety interventions. The care plan did not address the resident's non-compliance with call light use or include additional interventions tailored to the resident's specific risks and behaviors. Further review and interviews confirmed that the facility's interdisciplinary team was aware of the resident's fall risk and history but did not update the care plan to reflect the resident's ongoing needs and behaviors. The facility's policies required comprehensive, person-centered care plans based on thorough assessments and ongoing revisions as resident conditions changed. However, the care plan for this resident lacked specific, measurable interventions to address the identified risks, leading to a deficiency in care planning.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that four out of eight sampled residents were free from significant medication errors. Specifically, the licensed nurses did not check Resident 6's heart rate prior to administering Amiodarone as ordered, resulting in 26 instances of non-compliance over two months. Additionally, Resident 26 did not receive Mexiletine as prescribed, with missed and late doses documented, and the facility failed to ensure the medication was available for administration. The Quality Assurance Performance Improvement (QAPI) team did not identify or act to correct these errors, and the facility's policy on adverse consequences and medication errors was not followed. Resident 26 experienced significant issues with the administration of Mexiletine, a medication critical for treating life-threatening ventricular arrhythmias. The resident missed a dose on one occasion and received doses at intervals shorter than the prescribed eight hours on multiple occasions. The facility also failed to monitor Resident 26 for adverse effects when doses were missed or administered late. Furthermore, the communication between shifts regarding late administration was inadequate, leading to potential risks for the resident. The facility also failed to adhere to physician's orders for other residents. Resident 29 received Midodrine despite having a systolic blood pressure greater than the prescribed threshold, and Resident 30's blood pressure and pulse rate were not checked before administering Amiodarone. These deficiencies were compounded by the facility's failure to document vital signs accurately, with 'Not Applicable' being recorded instead of actual readings. The facility's policies on medication administration and error documentation were not followed, contributing to the risk of adverse consequences for the residents involved.
Removal Plan
- Resident 26 was seen by MD 2. The DON spoke to MD 2 and informed him Resident 26 missed a dose of Mexiletine and was given a late dose.
- The DON provided one on one training to the Licensed Vocational Nurses (LVNs) who documented Mexiletine's late and missed administration. The DON discussed the importance of making sure medications are available, the process of when to reorder medications, and process if dose was late or missed, physician notification, monitoring of residents for adverse effect for missing medications and development of change of condition Situation, Background, Assessment, Recommendation (SBAR) and care plan.
- The DON provided one on one counseling and in-service with LVN 2 in failing to administer the Mexiletine dose as scheduled and as ordered by the physician, the possible adverse effects of late administration and notification to the physician and monitoring of resident and/or responsible party if the schedule of the medication dose needs to be altered or changed.
- The DON provided a phone one on one counseling and in-service with involved LVN 3 in failing to administer the Mexiletine dose as scheduled and as ordered by the physician, and about the adverse effects of late administration including the process if the medication dose schedule needs to be altered or change such as notification to the physician. The DON will provide in-person counseling and in-service upon return to work of LVN 3 who failed to administer Mexiletine dose.
- The facility's contracted Pharmacy Consultant initiated an in-service with thirteen LVNs regarding administration of medications, the adverse effects of missing the dose and/or late medication administration. In-services will continue until all twenty-five LVNs have participated.
- The facility contracted Pharmacy Consultant is scheduled to do a Medication Regimen Review (MRR) for Residents receiving antiarrhythmic medications including Residents 6, 11, 20, 26, 30, 43, 51 and 70.
- The facility's Medical Director will initiate an in-service training with the seven LVNs on the importance of administering antiarrhythmic medications as ordered and at the specified time; the adverse effects of not administering medications or late administration, and adverse effects of overdosing on medications when administered medication too close between doses. The Medical Director will continue to conduct the in-service until the remaining eighteen LVNs have participated.
Failure to Address Medication Errors in QAPI Program
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to identify and address significant medication errors within the facility. During an interview, the Director of Nursing (DON) revealed that the current QAPI plan was focused on falls and discharges against medical advice, and medication administration errors were not included in their program. The DON admitted that they were unaware of the medication errors, which included missed doses, late administration, and not following physician's orders, until deficiencies were identified by surveyors. A review of the facility's policies and procedures indicated that medication errors were supposed to be documented, reported, and reviewed by the QAPI committee to inform necessary process changes or additional staff training. However, the QAPI program, as revised in February 2020, was not effectively implemented to monitor and evaluate these errors. This oversight placed all residents at risk for adverse effects due to the mismanagement of their medication regimen.
Failure to Provide Mandatory Communication Training for LVNs
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 2 and 3) received mandatory training in effective communication upon hire. During an interview and record review with the Director of Staff Development (DSD), it was found that the personnel records of LVN 2 and 3 lacked documented evidence of training in effective communication. The DSD confirmed that effective communication was not included in the orientation services for newly hired staff. In a subsequent interview with the Director of Nursing (DON), it was acknowledged that mandatory training needed to be implemented in the facility. The facility's policy and procedure, titled 'Competency of Nursing Staff' from May 2019, indicated that all nursing staff must meet specific competency requirements, including communication skills, as defined by state law. This oversight had the potential to result in staff with poor communication skills, which could negatively affect the residents' quality of care.
Failure to Provide QAPI Training to New LVNs
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 2 and 3) received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program upon hire. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), where it was found that the personnel records of LVN 2 and 3 lacked documented evidence of QAPI training. The DSD confirmed that QAPI training was not included in the orientation services for new staff. Additionally, the Director of Nursing (DON) acknowledged the need for mandatory training to be implemented in the facility. The facility's policy and procedure on the competency of nursing staff, dated May 2019, indicated that all nursing staff must meet specific competency requirements as defined by state law.
Failure to Update Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records of two residents were up to date concerning their Advance Directives (AD), as per the facility's policy. Resident 38 was admitted with several mental health diagnoses and was moderately impaired in cognitive skills. Upon admission, the AD Acknowledgement form was not discussed with Resident 38 due to their lack of alertness. The form was eventually signed on 12/5/2024, but it was deemed invalid as the resident was not capable of making medical decisions at that time. The Social Service Director and Director of Nursing acknowledged that the form should have been completed within 72 hours of admission during a care conference meeting. Resident 86 was admitted with conditions including atrial fibrillation and anxiety disorder, and was also moderately impaired in cognitive skills. The AD Acknowledgement form indicated that Resident 86 had an Advance Healthcare Directive (AHCD), but the facility did not have a copy of it. The resident did not recall discussing the AD Acknowledgement form, although they had spoken with their doctor about their wishes. The Director of Nursing noted that the form should have been completed during the admission process to ensure the facility had a copy of the AD. The facility's policy, revised in December 2016, requires that residents be provided with information about their right to formulate an AD upon admission. If a resident is incapacitated, the information should be given to their legal representative, and the resident should receive the information later if they become able to understand it. The policy also mandates that information about the existence of any AD be prominently displayed in the medical record. The failure to adhere to this policy resulted in the facility not being fully informed of the residents' wishes regarding their healthcare decisions.
Failure to Notify Physicians of Critical Medical Events
Penalty
Summary
The facility failed to notify the primary care physician of two residents regarding significant medical events. Resident 6, diagnosed with Diabetes Mellitus, had a critically high blood sugar level of 508 mg/dL, which was not communicated to the physician as required by the facility's policy. This oversight was confirmed through interviews and record reviews, where it was noted that the physician was not informed of the elevated blood sugar level, which was considered a change in condition necessitating immediate notification. Resident 26, who was on a strict medication regimen for ventricular tachycardia, experienced multiple instances of missed or late doses of mexiletine, a critical heart medication. The facility's records showed that doses were either missed or administered late on several occasions, yet there was no documentation that the physician was notified of these medication errors. Interviews with staff confirmed that these were considered medication errors and should have been reported to the physician for further instructions and monitoring. The facility's policies clearly outlined the need for prompt physician notification in cases of significant changes in a resident's condition or medication errors. However, in both cases, the facility did not adhere to these protocols, resulting in a lack of timely communication with the residents' physicians, which could have led to delays in necessary medical interventions.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect three residents from abuse and neglect, leading to significant deficiencies in care. Resident 69, who was diagnosed with end-stage renal disease, generalized muscle weakness, and hypertension, was allegedly sexually assaulted by another resident, Resident 1, in March 2023. Despite the incident being reported to the charge nurse and the Social Service Director (SSD), appropriate measures were not taken to ensure Resident 69's safety. Resident 1 was initially moved to another room but was later placed back near Resident 69, causing distress and fear for Resident 69. The facility did not adequately monitor or document the situation, failing to separate the residents effectively and ensure Resident 69's emotional well-being. In another incident, Resident 146, who had a history of dementia and aggressive behavior, was placed in front of the nursing station despite being agitated and combative. This placement led to a physical altercation with Resident 62, who was struck with a quad cane and punched by Resident 146. The facility did not take appropriate measures to separate Resident 146 from other residents, resulting in preventable abuse. The Director of Staff Development acknowledged that the situation was mishandled and should have been reported as abuse to the California Department of Public Health. The facility's policies and procedures regarding resident rights and abuse prevention were not followed, contributing to the deficiencies. The Social Service Director and other staff members failed to document and monitor the incidents properly, and the facility did not ensure the safety and well-being of the residents involved. These actions and inactions placed the residents at risk for further abuse and neglect, violating their rights to be free from harm.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of physical abuse involving two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. Resident 146, who has diagnoses including dementia and major depressive disorder, was involved in a physical altercation with Resident 62, who has diagnoses including major depressive disorder and PTSD. The incident occurred when Resident 146 grabbed Resident 62's quad cane and hit Resident 62 in the chest and arms. Despite the altercation being reported to the local police department and the ombudsman, it was not reported to CDPH as required by the facility's policy. The facility's policy on abuse investigation and reporting mandates that all reports of resident abuse and neglect be promptly reported to local, state, and federal agencies. The policy specifies that alleged violations involving abuse must be reported within two hours. The failure to report this incident to CDPH within the regulated timeframe resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.
Failure to Report Abuse Allegations to CDPH
Penalty
Summary
The facility failed to report allegations of physical abuse involving two residents to the California Department of Public Health (CDPH) within the required five-day period. Resident 62, who had intact cognitive skills and required assistance with daily activities, was involved in an altercation with Resident 146, who had moderately impaired cognitive skills and required substantial assistance with daily activities. The incident occurred when Resident 146 grabbed Resident 62's quad cane and hit Resident 62 in the chest and arms. The Director of Nursing (DON) confirmed that the altercation was reported to the local police department and the ombudsman but not to CDPH, and no investigative report was sent to CDPH. The facility's policy and procedure on abuse investigation and reporting, revised in April 2017, required the Administrator or designee to provide a written report of the findings to the appropriate agencies within five working days of the incident. This failure to report resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with PTSD, potentially leading to re-traumatization and negative impacts on their psychosocial status. Resident 62, who was admitted with major depressive disorder and PTSD, had intact cognitive skills and required assistance with daily activities. The resident's trauma history included exposure to war-related casualties, natural disasters, and life-threatening situations. Similarly, Resident 146, admitted with dementia, major depressive disorder, and PTSD, had moderately impaired cognitive skills and required varying levels of assistance with daily activities. This resident's trauma history also included exposure to war-related casualties, natural disasters, and life-threatening illnesses. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility did not assess the residents' triggers or develop trauma-informed care plans to address these triggers and prevent re-traumatization. The facility's policy on trauma-informed care emphasized the importance of minimizing triggers and re-traumatization for trauma survivors, particularly during the transition to an institutional setting. However, the facility did not implement these guidelines, resulting in a deficiency in providing appropriate care for residents with PTSD.
Medication Administration Errors Due to Incompetent Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses were competent during medication administration for four out of eight sampled residents, leading to significant medication errors. Resident 6, who had severe cognitive impairment and a history of heart disease, was supposed to receive amiodarone hydrochloride with specific instructions to hold the medication if the pulse was less than 60 BPM. However, the Medication Administration Record (MAR) showed that the pulse reading was marked as 'not applicable' multiple times, and the medication was still administered. Resident 26, with a history of ventricular tachycardia and cardiac arrhythmia, was prescribed amiodarone and mexiletine with specific administration times and conditions. The MAR indicated that doses were missed, administered late, or given without the required pulse readings. Additionally, the administration audit report showed that mexiletine was given at incorrect intervals, potentially leading to adverse effects. Resident 29, diagnosed with hypotension and atrial fibrillation, was to receive midodrine with instructions to hold the medication if the systolic blood pressure exceeded 130 BPM. Despite this, the MAR documented that the medication was administered even when the blood pressure was above the specified limit. Similarly, Resident 30, with atrial fibrillation and congestive heart failure, had medications administered without proper documentation of vital signs. Interviews with the Director of Nursing and Director of Staff Development revealed that the nurses were not following the facility's policy, leading to these medication errors.
Failure to Conduct IDT Meeting for Resident's Vision Decline
Penalty
Summary
The facility failed to ensure that an Interdisciplinary Team (IDT) Care Conference meeting was initiated for a resident, identified as Resident 86, after multiple eye doctor appointments. This oversight resulted in neither the staff nor the resident being aware of the outcomes from these appointments. The deficiency violated the resident's right to actively participate in the IDT meeting to discuss his plan of care and services, potentially delaying necessary discussions about needed care and services. Resident 86 was admitted to the facility with diagnoses including end-stage renal disease, type 2 diabetes, anemia, and hypertension. The resident had intact cognitive status and required assistance with various self-care and functional activities. Despite these needs, the last recorded IDT Care Conference Meeting for Resident 86 was on 6/27/2024, with no mention of vision decline. The resident reported seeing an eye doctor two months prior, who recommended surgery, but he was unaware of any arrangements for the procedure, and his vision was deteriorating. Interviews with facility staff, including a Licensed Vocational Nurse, Social Service Director, Assistant Director of Nursing, and MDS Nurse, revealed that there was no IDT meeting held in September 2024, despite the resident's reported vision decline and visits to an outside eye doctor. The facility's policy required IDT meetings for significant changes in a resident's condition, but this was not adhered to in Resident 86's case. The staff acknowledged that an IDT meeting should have been conducted to address the resident's vision issues and update the care plan accordingly.
Failure to Implement Vision Care Plan for Resident
Penalty
Summary
The facility failed to implement a care plan for a resident, identified as Resident 86, who experienced a decline in vision. This deficiency was identified during a survey that included observation, interviews, and record reviews. Resident 86 was admitted with multiple diagnoses, including end-stage renal disease, type 2 diabetes, anemia, and hypertension. Despite having intact cognitive status and the ability to make decisions about his care, there was no care plan addressing his vision decline, which was a concern he had verbalized since September. During the survey, it was observed that Resident 86 was aware of his need for eye surgery due to worsening vision, but there were no updates on the surgery's schedule. Interviews with the Licensed Vocational Nurse (LVN) and the MDS Nurse confirmed that there was no comprehensive care plan for the resident's vision issues, despite his ongoing visits to an eye doctor. The LVN acknowledged that a care plan should have been in place to ensure the healthcare team was aware of the interventions and to assess their effectiveness. The Director of Nursing (DON) also confirmed the absence of a care plan for the resident's vision decline. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the comprehensive assessment and to be revised as the resident's condition changes. However, this was not done for Resident 86, indicating a failure to adhere to the facility's care planning procedures.
Medication Order Lacks Specified Dose
Penalty
Summary
The facility failed to ensure that the medication order for a resident's diclofenac sodium external gel included a specified dose. This oversight resulted in the medication being administered without a documented dose from November 17, 2024, to December 3, 2024. The resident, who was readmitted to the facility with serious heart conditions and had severely impaired cognitive skills, received the medication for pain management without clarity on the amount to be applied. The lack of a specified dose in the medication order posed a risk of overdosing or underdosing the resident. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) acknowledged the absence of a specified dose in the Medication Administration Record (MAR) and recognized the need for clarification on the order. The Director of Nursing (DON) confirmed that medication orders must indicate the dose to ensure correct administration. The facility's policy and procedure for administering medication emphasized the importance of verifying the right dosage, among other factors, before administering medication. However, this policy was not adhered to in this instance, leading to the deficiency.
Deficient Foley Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate foley catheter care for a resident, identified as Resident 25, which led to the potential for recurrent urinary tract infections (UTIs). Resident 25 was admitted with several diagnoses, including obstructive and reflux uropathy, hypertension, benign prostatic hyperplasia, and mechanical complications of an indwelling urethral catheter. The resident required maximal assistance for various self-care activities and had intact cognitive status, allowing him to understand and make decisions about his care. The deficiency was identified through a review of Resident 25's Treatment Administration Record (TAR) for November 2024, which showed missing documentation for foley catheter care on multiple dates. The facility's policy required catheter care every shift, three times a day, and monitoring for signs of infection such as foul odor, hematuria, and sediments in urine. However, there were gaps in documentation, indicating that the care may not have been provided as ordered. During interviews, both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that if care was not documented, it was likely not provided. Observations and interviews with Resident 25 revealed that he had experienced frequent UTIs in the past, although he did not have one at the time of the interview. The facility's policy emphasized the importance of maintaining clean technique and regular monitoring to prevent catheter-associated UTIs. The lack of consistent documentation and adherence to the care plan increased the risk of Resident 25 developing recurrent UTIs, as confirmed by the DON during the interview.
Incorrect Oxygen Administration for Resident
Penalty
Summary
The facility failed to ensure that a resident was receiving the correct concentration of oxygen, which was a deviation from the physician's order. The resident, who was readmitted with diagnoses including interstitial pulmonary disease, pulmonary fibrosis, acute respiratory failure, and dependence on supplemental oxygen, was observed to have their oxygen set at 2.5 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an observation and interview. The ADON acknowledged the importance of adhering to the prescribed oxygen level to maintain proper lung function. The Director of Nursing (DON) also emphasized the necessity for staff to follow physician orders to ensure resident safety. The facility's policy on oxygen administration, revised in 2010, requires verification of the physician's order for safe oxygen administration, which was not followed in this instance.
Failure to Monitor Resident on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident who was prescribed psychotropic medications, which could lead to unnecessary medication use. The resident, who was admitted with diagnoses including dementia, major depressive disorder, PTSD, and limb amputations, was receiving Escitalopram for depression and anxiety, and Mirtazapine for sleep issues. However, there was no documented evidence that the resident's feelings of hopelessness, anxiety, or sleep patterns were monitored to assess the effectiveness of these medications. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility did not follow its policy and procedure for behavioral assessment, intervention, and monitoring. The policy required the interdisciplinary team to document any changes in behavior, mood, and function, and to monitor progress until stable. The lack of monitoring was acknowledged by the staff, indicating a failure to ensure the resident's behaviors were assessed to determine the necessity and effectiveness of the psychotropic medications.
Medication Security Lapse
Penalty
Summary
The facility failed to ensure the secure storage of medications, as evidenced by an incident involving Resident 70's medication. During a medication pass, an LVN placed Resident 70's Amiodarone on top of the medication cart and left it unattended. This action was observed on December 4, 2024, at 9:30 a.m. The unattended medication was later noticed by the Director of Staff Development, who confirmed that medications should not be left unattended to prevent unauthorized access by other residents. Resident 70 had been readmitted to the facility with serious cardiac conditions, including ventricular fibrillation and hypertensive heart disease with heart failure. The resident's cognitive skills for daily decision-making were severely impaired, as indicated by the Minimum Data Set dated November 23, 2024. The facility's policy on medication storage specifies that medication supply should only be accessible to authorized personnel, highlighting the importance of secure medication handling to ensure resident safety.
Failure to Sanitize Mechanical Lift Between Residents
Penalty
Summary
The facility failed to observe proper infection control measures when using a mechanical lift for two residents. Certified Nursing Assistant (CNA 1) and CNA 2 used the mechanical lift to transfer Resident 69, who required substantial assistance due to conditions such as end-stage renal disease and generalized muscle weakness, to a wheelchair. After completing the transfer, CNA 1 did not sanitize the mechanical lift before placing it in the hallway. Subsequently, CNA 1 used the same unsanitized lift to assist Resident 14, who was dependent on assistance for personal hygiene and dressing due to chronic kidney disease and anxiety disorder, into a Geri chair. During an interview, CNA 1 acknowledged forgetting to clean the mechanical lift between uses, recognizing the importance of this practice to prevent infection spread. The Director of Staff Development confirmed that equipment like mechanical lifts must be cleaned before and after use to prevent cross-contamination. The facility's policy on infection prevention and control, dated October 10, 2018, mandates maintaining a sanitary environment to prevent communicable diseases, which was not adhered to in this instance.
Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided a two-person physical assist when using a Mechanical Lift. The facility's policy requires at least two people to be present during transfers with a Mechanical Lift to ensure safety. However, CNA 1 attempted to transfer the resident alone, resulting in the resident falling from the lift and sustaining a right shoulder nondisplaced fracture. The resident, who was initially admitted to the facility with diagnoses including end-stage renal disease, generalized muscle weakness, and hypertension, was assessed as high risk for falls. The resident required substantial assistance for transfers and was dependent on staff for moving from one surface to another. On the day of the incident, the resident returned from dialysis and requested help to go to bed. CNA 1 attempted the transfer alone, leading to the resident falling and injuring their shoulder. Interviews with staff, including the Licensed Vocational Nurse (LVN), Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that the facility's policy mandates two-person assistance for transfers using a Mechanical Lift. The Occupational Therapist (OT) noted that the resident's right arm and shoulder range of motion were impaired following the fall, requiring therapy to regain function. The facility's policy, revised in October 2019, clearly states the requirement for two-person assistance during such transfers, which was not adhered to in this case.
Violation of Resident Rights and Dignity
Penalty
Summary
The facility failed to uphold and protect the rights of two residents, resulting in a deficiency related to resident dignity and respect. Resident 2, who has diagnoses including generalized anxiety disorder, major depressive disorder, and hemiplegia, experienced a violation of privacy and dignity when the Administrator (ADM) and Business Office Manager (BOM) entered his room without permission to discuss his outstanding balance. The ADM spoke to Resident 2 in a demeaning manner, questioning his financial decisions in a way that made him feel anxious and disrespected. This interaction was witnessed by Resident 2's roommate, who confirmed the disrespectful tone used by the ADM. Resident 3, diagnosed with anxiety disorder, major depressive disorder, and schizophrenia, was moved to another room against her wishes. Despite expressing her disagreement with the room change due to anxiety concerns, the ADM proceeded with the move to accommodate newly admitted residents near the nurse's station. The Ombudsman was contacted by Resident 3, who felt her rights were violated, and the ADM acknowledged the resident's refusal but decided to move her regardless. The facility's policy on room changes states that resident preferences should be considered, and residents have the right to refuse a move if it is for staff convenience. The facility's policies on resident rights and quality of life emphasize treating residents with dignity, respect, and privacy. However, the actions of the ADM in both cases did not align with these policies, leading to feelings of anxiety, humiliation, and a lack of trust among the affected residents. The ADM admitted to not having permission to discuss financial matters in Resident 2's room and acknowledged leaving the door open during the conversation, further compromising privacy. These actions contributed to the deficiency in maintaining resident dignity and respect.
Delayed Emergency Response for Choking Resident
Penalty
Summary
The facility failed to promptly activate Emergency Medical Services (EMS) and provide appropriate emergency care when a resident was observed choking while eating. The incident involved a resident with a history of dysphagia and severely impaired cognitive skills, who was dependent on staff for eating. During the choking episode, the resident's oxygen saturation fluctuated between 52% and 82%, and the staff administered oxygen at an insufficient rate via a nasal cannula instead of using a non-rebreather mask, which would have been more effective. The delay in calling 911 was due to the actions of RN 1 and LVN 1, who prioritized checking the resident's code status and consulting with the Director of Staff Development (DSD) over immediately contacting emergency services. This resulted in a 14-minute delay before EMS was called. Additionally, the staff failed to retrieve the crash cart and a non-rebreather mask, which were necessary for providing adequate emergency care to the resident. Interviews with staff members revealed a lack of clear communication and delegation during the emergency. CNA 1 and CNA 2 were not instructed to call 911 or retrieve the crash cart, and LVN 1 did not inform RN 1 about performing the Heimlich maneuver. The Director of Nursing (DON) and DSD acknowledged that the facility's response was inadequate, emphasizing that 911 should have been called immediately and the crash cart should have been brought to the resident's room to prevent a delay in care.
Failure to Document Choking Incident and Care
Penalty
Summary
The facility failed to document the care provided to a resident who experienced a choking incident during dinner. The resident, who had a history of dysphagia and severely impaired cognitive skills, was being fed noodles by a CNA when they began to choke. The CNA called for assistance, and an LVN performed the Heimlich maneuver, successfully expelling food particles from the resident's mouth. However, the LVN did not document the incident or the care provided in the resident's medical record, citing being busy as the reason for the oversight. This lack of documentation resulted in an incomplete medical record for the resident, which did not reflect the choking incident or the subsequent care provided. The facility's policy required detailed documentation of such incidents, including the time, assessment data, and the resident's response. The failure to document prevented accurate communication between healthcare professionals and hindered the facility's ability to review and investigate the incident thoroughly.
Failure to Resolve Resident's Grievance Regarding Missing Belongings
Penalty
Summary
The facility failed to resolve a grievance to the satisfaction of a resident and their representative regarding missing personal belongings, specifically a cellphone. The resident, who was admitted with diagnoses including sepsis, depression, and hemiparesis, had intact cognition and required supervision for activities of daily living. The resident's inventory list included a black cellphone, which was reported missing along with other items such as a backpack, checkbook, and social security card. Despite the grievance being filed, the resolution did not address the cellphone, which was inventoried, and the resident's representative expressed dissatisfaction with the lack of replacement or reimbursement. The facility's policy required prompt resolution of grievances to the satisfaction of the resident or their representative, but this was not achieved. The Social Services Director acknowledged that the cellphone should have been replaced or reimbursed, as it was listed in the inventory. The Administrator, however, stated that the resident had the ability to safeguard their belongings and was not satisfied with the resolution. The facility's grievance policy indicated that all grievances should be responded to in writing with a rationale, but this was not adequately fulfilled in this case.
Delayed Family Notification of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a family member in a timely manner when there was a change of condition for a resident. The resident, who was admitted with diagnoses including congestive heart failure, obstructive and reflux uropathy, and unspecified dementia, had mildly impaired cognitive skills and required moderate assistance for various activities of daily living. On a specific date, the resident pulled out his Foley catheter, resulting in moderate bleeding at the penile tip. The physician was notified at 3:22 a.m., but the family was not informed until 8:00 a.m., leading to dissatisfaction and concern from the family. The Assistant Director of Nursing (ADON) acknowledged the delay in notifying the family and stated that the facility's protocol requires prompt notification of any change in a resident's condition. The facility's policy and procedure documents also emphasize the importance of promptly informing the resident, their physician, and their representative of any changes in medical or mental condition. The ADON admitted that a five-hour delay in notifying the family was not acceptable, although the facility did attempt to inform them. The family expressed upset over the lack of immediate notification and the decision not to send the resident to the hospital immediately after the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Palms Healthcare | 0.1 mi | — | 41 | 0 |
| Coral Cove Post Acute | 0.4 mi | — | 6 | 0 |
| Ocean Ridge Post Acute | 0.4 mi | — | 23 | 0 |
| Shoreline Healthcare Center | 0.6 mi | — | 3 | 0 |
| Bel Vista Healthcare Center | 0.6 mi | — | 3 | 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.