Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Mayers Memorial Hospital during CMS and state inspections, most recent first.
A resident with paraplegia and COPD, who was cognitively intact, was transferred to an acute care hospital for respiratory issues and confusion, but the facility failed to follow its own policies for transfer and discharge. The resident did not receive or sign a 7‑day bed-hold form, there was no dual-nurse verification of verbal consent, and neither the resident nor family were informed of bed-hold provisions or the right to appeal the discharge. No discharge physician order was obtained, and there was no documented discussion with the resident or representative about discharge. Additionally, no change in condition assessment was completed, and the resident’s care plan was not updated to reflect the hospital transfer and change in health status.
Two residents were denied access to portable oxygen tanks due to repeated equipment failures, forcing them to use large, non-portable concentrators that restricted their movement and participation in activities. Both residents reported feeling embarrassed and confined, and staff confirmed ongoing issues with the oxygen supply system and the impact on residents' daily lives.
Surveyors found that multiple resident bathrooms had unsanitary conditions, including missing or damaged caulking around toilets, grime buildup, and floors in disrepair. Staff and a family member confirmed the bathrooms were not clean or homelike, and facility policies requiring daily cleaning and maintenance were not followed.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
A controlled medication bin was found sealed with a zip tie whose number did not match the number recorded on the controlled count sheet. This discrepancy was confirmed by a nurse and acknowledged by the DON, indicating a failure to accurately document and secure controlled substances as required by facility policy.
Pharmacy recommendations for medication regimen reviews were not addressed by the physician, DON, or nursing staff for three residents, including those with dementia and complex medical histories. Recommendations regarding antipsychotic use, high-risk medication combinations, and the need for behavior documentation and dose reductions were left unanswered for several months, contrary to facility policy.
Two residents experienced medication errors when a nurse was unable to administer a prescribed antibiotic due to unavailability and another resident received omeprazole after breakfast instead of on an empty stomach as ordered. These incidents resulted in a medication error rate above 5%, with issues including lack of medication availability and discrepancies between the MAR and physician orders.
Surveyors found expired insulin lispro and tuberculin purified protein derivative vials in medication storage areas. Nursing staff and administration confirmed these medications were expired and should have been removed according to facility policy and manufacturer guidelines.
A licensed nurse used the same blood pressure monitor on multiple residents during medication pass without cleaning or disinfecting the device between uses. Both the nurse and DON acknowledged that the equipment should be sanitized between each resident, and facility policy as well as manufacturer instructions required cleaning after each use. This failure breached infection prevention and control protocols.
The facility did not ensure the pharmacist established and maintained records for controlled medications, leading to undetected diversion of narcotics. A nurse was observed removing narcotic cassettes, and an audit found thousands of missing narcotic tablets and vials, with missing documentation and lack of pharmacy tracking. The pharmacist was unaware of regulatory responsibilities and did not perform required audits or collaborate with staff to ensure safe handling of controlled substances.
Two residents with significant fall risk factors, including dementia and mobility issues, experienced avoidable falls resulting in hip fractures and hospitalizations after staff failed to follow care planned interventions. One resident was not assisted to bed or the bathroom as required, and another was not provided with non-skid footwear, leading to falls and injuries. The facility's policy and care plans were not followed, contributing to these incidents.
Two residents with severe cognitive impairment experienced physical and verbal abuse when one CNA was rough and pushed a resident, while another CNA cursed, pushed a resident, and threw personal care items onto the resident's chest. These actions were witnessed by staff and other residents, and resulted in emotional distress and fear for the affected residents.
A facility failed to thoroughly investigate an allegation of staff-to-resident abuse when a resident with severe cognitive impairment was allegedly mistreated by a CNA. Although a roommate witnessed the incident and confirmed she was not interviewed, the facility's investigation did not include her account, and the DON acknowledged this omission.
A resident with dementia was not promptly monitored or documented for changes in condition after experiencing abuse by a CNA. Required change in condition charting was not completed immediately, and alert charting to monitor the resident for 72 hours was initiated late, contrary to facility policy.
The facility did not follow its abuse reporting policy for several residents, including failing to send investigation results to CDPH after altercations between residents and not reporting a family member's verbal abuse of a resident within the required timeframe. These lapses involved residents with dementia, mood disorders, and other chronic conditions, and resulted in delayed or missing notifications to regulatory authorities.
A resident experienced verbal abuse from an RN who yelled and cursed at her, instructing her not to use her call light. The resident, with a BIMS score indicating good memory and decision-making skills, reported the incident, which was corroborated by CNAs. The facility's investigation substantiated the abuse, and the resident's medical history included COPD, cognitive decline, insomnia, diabetes, depression, and hypertension.
A CNA in an LTC facility verbally abused five residents, including those with dementia, stroke, and Parkinson's disease. The CNA refused to provide food to a resident in pain, made derogatory comments about another's size, and was described as unprofessional and disrespectful by others. These incidents were corroborated by staff and documented in facility records.
Two residents at an LTC facility eloped due to inadequate assessment and monitoring for wandering and elopement risks. One resident with severe cognitive impairment was found in the parking lot, while another with moderate impairment was located at a gas station by law enforcement. Risk assessments for both were completed only after the incidents.
The facility did not meet the required daily RN hours for PBJ staffing information submitted to CMS. The Quality Manager confirmed that RN coverage was not met for 20 days in the first Federal Quarter of 2024, with no RNs present on the schedule for these dates. The XML Submission Form showed specific dates with gaps in RN coverage, confirming the deficiency.
The facility failed to report abuse allegations in a timely manner for several residents. One resident was verbally and physically abused by the DON, and staff did not report the incident due to fear and lack of knowledge. Another incident involved two residents, where one hit the other, but the report was delayed. The facility lacked a culture that supported abuse reporting.
The facility failed to review and revise the Care Plans for two residents when information about their risk for elopement and exit alarm devices was not included. Both residents had severe cognitive impairment and physician's orders for Wander guard devices, but their Care Plans lacked entries about elopement risk or the devices. The ADON confirmed the omission and mentioned that a new elopement policy was being drafted.
The facility failed to ensure the environment was free of accident hazards for two residents with orders for Wanderguard devices but lacked follow-up or monitoring. Both residents had severe cognitive impairments and were not wearing the Wanderguard devices as ordered, with no documentation in the MAR to monitor elopement behaviors. The ADON confirmed the lack of documentation and mentioned an unapproved new elopement policy.
The facility failed to protect a resident from physical and verbal abuse when the DON was observed yelling at and shaking the resident's wheelchair. The resident, who has a history of high blood pressure, intellectual disability, and traumatic brain injury, was wheeling herself backwards down the hallway when the incident occurred. This behavior violated the facility's policy on abuse and has caused the resident to feel afraid to leave her room.
The facility failed to ensure professional food safety and sanitation practices, as evidenced by an unclean microwave, expired food items, improperly labeled bagels, and a dented can of soup. These deficiencies were confirmed by the Certified Dietary Manager and had the potential to result in foodborne illness for the facility's 79 residents.
Failure to Provide Proper Bed-Hold Notice, Discharge Orders, and Care Plan Updates After Hospital Transfer
Penalty
Summary
The facility failed to ensure an appropriate transfer and discharge process for a resident who was transferred from the SNF to an acute care hospital for shortness of breath and confusion. The resident had paraplegia and COPD and had a BIMS score of 15/15, indicating intact decision-making ability. When the resident was sent to the hospital, the facility did not obtain a signed 7‑day bed hold form from the resident or her representative, nor did two nurses document a verified telephone agreement as required by facility policy. The DON confirmed that the bed-hold document in the record lacked the resident’s or responsible party’s signature and did not contain the required dual-nurse verification. The resident’s family member reported that neither the resident nor the family received the bed-hold information form or any information about appealing the discharge, and that the only communication received was that the resident’s belongings were packed and ready for pickup while the resident remained hospitalized. The facility also did not follow its transfer and discharge policy regarding physician orders and communication. Review of the resident’s order summary showed no discharge physician’s order, despite the resident not returning to the facility. Progress notes contained no documentation of any conversation with the resident or her responsible party about discharge from the facility, contrary to the policy requiring completion and review of a transfer/discharge summary and instructions with the resident and/or family. The DON confirmed the absence of a discharge order and the lack of documented discussion about discharge. In addition, the facility did not complete required assessments or update the care plan in response to the resident’s change in condition and transfer. The charting and documentation policy required recording any significant change in condition, but review of progress notes from the date of transfer through the survey date showed no change in condition assessment, which the DON confirmed. The care plan policy required review and revision of the care plan with changes in health status, yet the resident’s care plan, initiated previously, contained no updates related to the transfer to the acute care hospital for respiratory issues. These omissions resulted in the resident not being properly involved in or prepared for discharge and not being informed of the right to appeal the discharge, as stated in the report.
Failure to Provide Portable Oxygen Tanks Limits Resident Dignity and Mobility
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect by not providing access to portable oxygen tanks. Instead, residents were required to use large, noisy, non-portable oxygen concentrators that needed to be plugged into electrical outlets. This limitation prevented the residents from moving freely within the facility, going outdoors, attending appointments, or leaving with family, as the concentrators were cumbersome and required constant access to electricity. The issue was ongoing due to repeated malfunctions of the equipment used to fill portable tanks, and the facility's oxygen service provider was frequently called for repairs, but the problem persisted. Resident records indicated that one resident had severe cognitive impairment and was not their own representative, while the other had intact cognition and made their own medical decisions. Both residents expressed feelings of embarrassment, confinement, anger, and anxiety due to their restricted mobility and reliance on the concentrators. Staff interviews confirmed the recurring equipment failures, the need for staff assistance to move the concentrators, and the resulting impact on residents' ability to participate in activities and outings. The facility's own resident rights documentation emphasized the right to dignity and individuality, which was not upheld in this situation.
Unsanitary Resident Bathrooms and Lack of Homelike Environment
Penalty
Summary
Surveyors observed that 6 out of 8 resident bathrooms had unsanitary conditions, including gaps around toilet bases where caulking was torn or missing, resulting in grime and discolored buildup that resembled urine or fecal matter. The linoleum flooring in these bathrooms was described as old, scratched, and in disrepair, with additional observations of loose dirt debris, black scuff marks, and yellow staining. These conditions were confirmed by both family members and staff, who stated that the bathrooms were not in acceptable or sanitary condition. Facility documentation indicated that housekeeping procedures required daily and thorough cleaning of environmental surfaces, but these standards were not met in the observed bathrooms. Interviews with staff, including the Assistant Director of Nursing and Environmental Services Manager, acknowledged awareness of the maintenance and cleanliness issues in the resident restrooms. Both staff and family members expressed that the bathrooms were not maintained to a homelike or sanitary standard, with one family member stating they would not allow their home restroom to be in such a condition. The facility's own policies required a clean, sanitary environment, but observations and interviews confirmed that these expectations were not being fulfilled in the resident bathrooms at the time of the survey.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Inaccurate Controlled Drug Record-Keeping
Penalty
Summary
The facility failed to maintain accurate pharmacy services for its census of 69 residents when the controlled drug record form was not properly filled out and signed. During an inspection of the controlled medication bin, it was observed that the bin was locked and sealed with a numbered zip tie that did not match the number recorded on the controlled count sheet. The discrepancy was confirmed by a charged nurse, who acknowledged the error, and the DON recognized the potential risk associated with mismatched tag numbers. Review of facility policy indicated that discontinued medications and controlled substances are to be handled securely, but the observed practice did not align with this requirement.
Failure to Respond to Pharmacy Recommendations for Medication Regimen Reviews
Penalty
Summary
A deficiency occurred when pharmacy recommendations were not followed or responded to by the physician, DON, or nursing staff for three of six sampled residents over periods extending up to ten months. For one resident with dementia, chronic kidney disease, and emphysema, the physician failed to respond to the pharmacist's recommendations regarding the use of Rexulti for agitation for five months. Another resident with a history of stroke, dementia, and nerve pain had a high-risk medication combination of gabapentin and an opioid, with the pharmacist requesting a risk-benefit analysis and effectiveness documentation, but the physician did not respond for ten months. A third resident with dementia and aggressive behaviors was prescribed Zyprexa, and the pharmacist's repeated recommendations for a gradual dose reduction and improved behavior documentation went unaddressed for four consecutive months. The facility's policy required that the consultant pharmacist review medication regimens and that the physician respond to recommendations, documenting the rationale for continuing medications if indicated. However, clinical record reviews showed a lack of physician or nursing staff response to the pharmacist's recommendations in the medical records for the residents involved. The pharmacist confirmed that reminders were given to the DON and nursing staff regarding the need for specific behavior documentation and consideration of dose reductions, but these recommendations remained unaddressed.
Medication Error Rate Exceeds 5% Due to Missed and Improperly Timed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two errors identified out of 31 opportunities during medication administration observations. For one resident, a licensed nurse was unable to administer doxycycline as ordered for bronchitis because the medication was not available at the time of administration. The nurse reported that the prescription had been extended by the provider, but the medication had not yet been received from the pharmacy, resulting in a missed dose. Facility policy requires that medications be administered as prescribed and available for administration. In another instance, a licensed nurse administered omeprazole to a resident after the resident had already consumed half of their breakfast, despite physician orders specifying that the medication should be given on an empty stomach before breakfast for gastrointestinal protection. The nurse acknowledged that the order summary on the MAR did not match the prescription label, and the MAR had not been updated to reflect the correct administration time. Facility policy requires that medications be administered at the correct time and as prescribed, with accurate reconciliation between the MAR and physician orders.
Expired Medications Found in Storage Areas
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and removal of expired medications. During an inspection of a medication cart, an expired insulin lispro pen was found with an expiration date that had already passed. The licensed nurse present acknowledged the medication was expired and confirmed it should have been removed. Review of the medication's provider information indicated that insulin lispro should not be used past its expiration date and that opened vials should be discarded after 28 days. The Director of Nursing stated that nurses are expected to check for expired medications each time they take over the cart, and that expired insulin pens should be dated and replaced. Additionally, an expired multi-dose vial of tuberculin purified protein derivative testing agent was found in a medication room refrigerator. The vial was labeled with an open date and a discard date that had already passed. The Assistant Director of Nursing confirmed the medication was expired and should have been removed from active storage. Facility policy and procedure documents reviewed by surveyors stated that outdated medications are to be removed from storage areas and are not to be available for patient use.
Failure to Disinfect Blood Pressure Monitor Between Resident Uses
Penalty
Summary
The facility failed to follow infection prevention and control practices when a blood pressure monitor was not disinfected according to the manufacturer's instructions after use during medication pass observations. On multiple occasions, a licensed nurse used the same blood pressure monitor to measure the blood pressure of different residents in their rooms and then placed the device back on the medication cart without cleaning or disinfecting it between uses. This practice was observed with several residents during the medication pass. During interviews, the licensed nurse acknowledged that the blood pressure monitor and cuffs were not cleaned or sanitized between residents, and the Director of Nursing confirmed that the equipment should be disinfected between each use to reduce infection risk. Review of the facility's policy and the manufacturer's cleaning recommendations indicated that both the monitor and cuff should be cleaned with a soft, moistened cloth and mild detergent after each use to maintain hygiene. The failure to adhere to these procedures constituted a breach of infection control protocols.
Failure to Maintain Controlled Substance Records and Oversight by Pharmacist
Penalty
Summary
The facility failed to ensure that the pharmacist was responsible for establishing and maintaining a system of records for the receipt and disposition of all controlled medications, as required by federal regulations. The facility's policy required consistent receiving and tracking of controlled substances to prevent and detect diversion, but this was not followed. A narcotic reconciliation issue was identified when an LVN requested additional narcotics for a resident before it was due, and video surveillance later showed the LVN removing narcotic cassettes from the locked medication room. An audit revealed that 2550 narcotic tablets and 2 vials of morphine were missing, with missing paperwork on 85 narcotic cassettes and 2 vials of liquid morphine. The facility identified contributing factors such as lack of overflow accountability and the pharmacy not tracking required control sheets, with leadership changes cited as a root cause for process failures. The pharmacist stated he was unaware of his federal responsibilities and had not established or maintained records of receipt and disposition of controlled medications, nor performed routine audits to reconcile narcotic drug usage or collaborated with facility staff to ensure safe and secure handling of these drugs. The pharmacist believed his responsibility ended once the narcotics were dispensed to nursing, and he relied on DEA software alerts to identify issues. This lack of oversight and failure to follow established procedures allowed narcotic medications to be diverted without detection.
Failure to Implement Care Planned Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement care planned fall prevention interventions for two residents who were identified as high risk for falls. For one resident with diagnoses including dementia, rheumatoid arthritis, prostate cancer, vision problems, and high blood pressure, the care plan required staff to follow the resident to his room and assist with toileting or lying down. Despite this intervention, the resident experienced multiple falls in his room, including an incident where he attempted to transfer himself from his wheelchair to his bed, resulting in a fractured right hip that required surgical repair. The Director of Nursing confirmed that staff did not follow the care plan intervention at the time of the fall. Another resident, also at high risk for falls due to conditions such as dementia, depression, anxiety, insomnia, repeated falls, chronic pain, heart failure, lung disease, incontinence, arthritis, osteoporosis, and prior fractures, had a care plan intervention to ensure the use of non-skid footwear when ambulating or mobilizing in a wheelchair. This intervention was not followed, and the resident was found wearing slippers that were not non-skid at the time of a fall. The resident attempted to self-transfer from a wheelchair to a recliner, slipped, and sustained a fractured left hip requiring surgical repair. A post-fall committee meeting identified inappropriate footwear as the root cause of the fall, and a nurse confirmed the care plan was not followed. Both residents had documented histories of falls and were assessed as high risk using the Morse Fall Scale. The facility's own policy required the implementation of evidence-based interventions for residents at risk for falls, including addressing fall risks in care plans and providing non-skid footwear. The failure to follow these care planned interventions directly resulted in avoidable falls and serious injuries for both residents.
Failure to Prevent Physical and Verbal Abuse of Residents
Penalty
Summary
The facility failed to prevent physical and verbal abuse for two residents with severe cognitive impairment. One resident, diagnosed with dementia, chronic pain, and weakness, was reported by her roommate to have been pushed and handled roughly by a CNA. A nursing note documented that this resident was emotional and distraught following the incident. Another resident, also with dementia and a severely impaired BIMS score, experienced an incident where a CNA cursed, pushed the resident, and threw personal care items onto the resident's chest. A witness CNA reported that the resident expressed fear of the CNA due to her aggressive behavior. The facility's policy prohibits all forms of abuse and mistreatment, but interviews and record reviews confirmed that staff members engaged in rough and aggressive conduct toward these residents. The incidents were directly observed or reported by other staff and residents, and the affected residents were noted to be emotionally distressed and fearful as a result of the staff's actions.
Failure to Interview Witness During Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident abuse involving a resident with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. According to facility policy, all suspected incidents of abuse require obtaining written statements from all persons involved and conducting staff and resident interviews. However, despite a roommate witnessing the alleged abuse and confirming she was not interviewed, the facility's investigation records did not include an interview with this witness. The Director of Nursing confirmed that no interview was conducted with the roommate, despite her being a witness to the incident.
Failure to Timely Monitor and Document After Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident who experienced abuse was properly monitored for any resulting problems. Specifically, after a Certified Nursing Assistant (CNA) was rough with the resident and threw personal care items at him, staff did not complete required change in condition charting immediately following the incident. Additionally, alert charting, which is meant to provide ongoing documentation and monitoring for 72 hours after such incidents, was not initiated until two days after the event. These actions were not in accordance with the facility's own policies, which require documentation of significant changes in condition and monitoring after abuse or unusual occurrences. The resident involved had a diagnosis of dementia, which affects memory and decision-making abilities. Review of the resident's progress notes confirmed the absence of timely change in condition documentation and a delay in starting alert charting. The Assistant Director of Nursing verified that these documentation requirements were not met as per policy following the incident of abuse.
Failure to Timely Report and Document Abuse Investigations
Penalty
Summary
The facility failed to follow its abuse reporting policy for six out of fourteen residents sampled for abuse. In multiple instances, altercations and allegations of abuse between residents, as well as an incident involving a family member verbally abusing a resident, were either not reported to the California Department of Public Health (CDPH) as required or were reported late. The facility's policy mandates that results of abuse investigations be reported to the appropriate authorities, including CDPH, with documentation of dates and times. For one incident, a resident with vascular dementia threw a plate at another resident with dementia and chronic pain. Although an initial report was made, the follow-up investigation results were not sent to CDPH as required by policy. In another case, a resident with dementia, stroke, and dysphagia was involved in altercations with two other residents, one involving physical contact and another involving verbal aggression. Investigations were conducted for both incidents, but there was no documentation that the results were reported to CDPH. Additionally, a resident with dementia, mood disturbance, and anxiety was verbally abused by a family member during a visit. Staff overheard the family member using profanity and belittling the resident. The incident was not reported to CDPH within the required 24-hour timeframe, instead being reported 46 hours after the event. These failures to report and document abuse investigations as per facility policy had the potential to subject residents to mistreatment, neglect, or abuse.
Verbal Abuse by RN Towards Resident
Penalty
Summary
The facility failed to prevent verbal abuse towards a resident by a registered nurse (RN A). The incident involved RN A yelling and cursing at the resident, instructing her not to use her call light, which caused the resident distress and feelings of unmet needs. The resident, who had a BIMS score indicating good memory and decision-making skills, reported the verbal abuse, which was corroborated by witness statements from certified nursing assistants (CNAs). These statements detailed RN A's frustration with the resident's frequent use of the call light and included instances of RN A turning off the call light and instructing CNAs to ignore the resident's calls unless it was an emergency. The resident's medical history included chronic obstructive pulmonary disease, age-related cognitive decline, insomnia, diabetes, depression, and hypertension. Despite these conditions, the resident expressed satisfaction with the facility overall. However, the verbal abuse incident was substantiated by the facility's investigation, which included a review of witness statements and an email from RN A acknowledging the difficulty in working with the resident. The Director of Nursing confirmed the findings of verbal abuse during an interview.
Verbal Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect five residents from verbal abuse by a Certified Nurse Assistant (CNA 1). Resident 1, who suffers from dementia, anxiety, spinal stenosis, and high blood pressure, reported that CNA 1 refused to provide food unless the resident sat up, despite the resident's pain. This incident was corroborated by another CNA and an Activities Aide, who both witnessed CNA 1's rude behavior. Additionally, CNA 1 was reported to have taken away Resident 1's dinner tray, causing distress to the resident. Resident 2, who has a history of stroke, obesity, hearing loss, and arthritis, was also subjected to verbal abuse. CNA 1 was overheard yelling that Resident 2 was too big to handle alone and made derogatory comments about the resident's size. This behavior was documented in the facility's progress notes and reported by other staff members. Resident 3, who is cognitively intact and has obesity, fibromyalgia, and diabetes, described CNA 1 as a bad CNA, although the resident did not provide further details. Resident 4, diagnosed with Parkinson's disease, cancer, and a history of falls, expressed that CNA 1 was unprofessional and disrespectful, making the resident feel belittled. The resident reported that CNA 1 did not listen and made dismissive comments. Similarly, Resident 5, who has Alzheimer's, a hip replacement, anxiety, and arthritis, stated that CNA 1 was bossy and rushed the resident, refusing assistance to the toilet. These incidents were documented in the facility's records and reported by the residents to the nursing staff.
Failure to Assess and Monitor Residents for Wandering and Elopement Risks
Penalty
Summary
The facility failed to ensure proper assessment and monitoring for two residents who were at risk for unsafe wandering and elopement. Resident 1, who had a severe cognitive impairment due to an anoxic brain injury, eloped from the facility and was found in the parking lot by a staff member. Despite wearing a Wander Guard, the resident's wandering and elopement risk assessments were only completed after the incident occurred, two months post-admission. Resident 2, with moderate cognitive impairment and medical diagnoses including cancer, depression, and anxiety, was found by law enforcement at a gas station after eloping from the facility. The resident's wandering and elopement risk assessments were not completed until nearly five months after the incident. Interviews with facility staff confirmed that the assessments for both residents were not conducted until after their respective elopements.
Failure to Meet Required RN Coverage
Penalty
Summary
The facility failed to meet the required daily Registered Nursing (RN) hours for Payroll Based Journaling (PBJ) staffing information submitted to the Centers for Medicare and Medicaid Services (CMS). During a concurrent record review and interview, the Quality Manager (QM) confirmed that the required RN coverage was not met for 20 days of the first Federal Quarter of 2024. The QM acknowledged that there were no RNs present on the schedule for these dates, although RNs were encouraged to clock in when providing resident care. The QM reviewed the XML Submission Form with the surveyor, pointing out specific dates where gaps in RN coverage were evident, confirming that no RNs were listed for resident care as required by CMS.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report abuse allegations in a timely manner for several residents. One resident, who was cognitively intact and had a history of high blood pressure, intellectual disability, and traumatic brain injury, was verbally and physically abused by the Director of Nursing (DON). The DON yelled at the resident and physically shook her wheelchair, causing the resident to feel embarrassed and in tears. Staff members were aware of the incident but did not report it due to fear of retaliation and a lack of understanding of reporting procedures. The incident was not reported to the California Department of Public Health as required by regulations. Another incident involved two residents, one with severe cognitive impairment and the other with behavioral disturbances. A Certified Nurse Assistant (CNA) witnessed one resident hitting the other in the hallway. The incident was documented in the clinical records but was reported late to the appropriate authorities. The facility's policy requires that such incidents be reported within two hours, but this was not adhered to. Interviews with staff revealed a lack of knowledge about the abuse coordinator and the proper procedures for reporting abuse. The Quality Manager acknowledged that the facility did not have a culture that supported reporting abuse, which contributed to the failure to report the incidents in a timely manner. The facility's training program on abuse reporting was reviewed, and it was confirmed that staff were educated to report suspected abuse within two hours, but this protocol was not followed in these cases.
Failure to Include Elopement Risk and Wander Guard Devices in Care Plans
Penalty
Summary
The facility failed to review and revise the Care Plans for two residents when information about their risk for elopement and exit alarm devices was not included. Resident 27, who had severe cognitive impairment and a history of anoxic brain damage and a prior heart attack, had a physician's order for a Wander guard device to be applied for safety. However, the Care Plan for Resident 27 did not include any entries about elopement risk or the Wander guard device. Similarly, Resident 128, who had severe cognitive impairment, dementia, anxiety, and legal blindness, also had a physician's order for a Wander guard device. Yet, Resident 128's Care Plan also lacked entries about elopement risk or the Wander guard device. During an interview and record review, the Assistant Director of Nursing (ADON) confirmed that the elopement risk and Wander guard devices were not included in the Care Plans for Residents 27 and 128, and acknowledged that they should have been. The ADON mentioned that they usually discussed elopement risk during the resident's Care Conference and were in the process of drafting a new elopement policy, which had not yet been approved.
Failure to Monitor Wanderguard Devices for Residents
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards for two residents who had orders for Wanderguard placement but lacked follow-up or monitoring. Resident 27, who had severe cognitive impairment and a history of anoxic brain damage and a prior heart attack, was admitted with a physician's order for a Wanderguard device to be applied to their left ankle and checked every shift. However, there was no documentation in the Medication Administration Record (MAR) to monitor elopement behaviors, and during an observation, it was confirmed that Resident 27 was not wearing the Wanderguard device as ordered. Additionally, the Multidisciplinary Care Conference note did not mention the risk of elopement or the Wanderguard device, indicating a lack of proper documentation and follow-up on the resident's care plan. Similarly, Resident 128, who had severe cognitive impairment, dementia, anxiety, and legal blindness, had a physician's order for a Wanderguard device to be applied and checked twice a day. However, the MAR also showed no monitoring for elopement behaviors. During an interview, the Assistant Director of Nursing (ADON) confirmed that Resident 128 was not wearing the Wanderguard device as ordered and acknowledged the lack of documentation. The ADON mentioned that an initial elopement risk assessment is usually done on admission, but there was no documentation to support this for Resident 128. The facility was in the process of drafting a new elopement policy, which had not yet been approved, further highlighting the gap in ensuring resident safety from elopement risks.
Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
The facility failed to ensure that Resident 10 was free from physical and verbal abuse. The incident occurred when the Director of Nursing (DON) was observed by a confidential informant (CI1) yelling at and shaking Resident 10's wheelchair. Resident 10, who has a history of high blood pressure, intellectual disability, and traumatic brain injury, was wheeling herself backwards down the hallway due to weakness in her right side extremities. After accidentally bumping into another resident, the DON came out of her office, yelled at Resident 10, and physically shook her wheelchair, causing Resident 10 to feel embarrassed and cry. This incident was corroborated by interviews with Resident 10 and two confidential informants (CI1 and CI2), who confirmed the DON's inappropriate behavior and frequent yelling at residents. The facility's policy and procedure on abuse, dated 7/15/2022, clearly states that residents have the right to be free from all forms of abuse, including verbal and physical abuse. Despite this policy, the DON's actions violated these guidelines, resulting in physical and verbal abuse of Resident 10. The incident has led to Resident 10 feeling afraid to leave her room due to fear of being yelled at again. The failure to protect Resident 10 from abuse has the potential to negatively impact her psychosocial wellbeing and lead to isolation.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure professional food safety and sanitation practices were in place, as evidenced by several deficiencies observed during a kitchen inspection. The interior of the microwave oven used to prepare resident food was found to be unclean, with red-colored material splattered on its ceiling and sides. Additionally, two plastic bags containing grated cheese were found to be expired, and a sealed bottle of a nutritional shake had a printed expiration date that had passed. Furthermore, three bagels were stored in a plastic bag without a use-by date, and a large can of soup was dented along its seam, which should have been discarded. These deficiencies were confirmed by the Certified Dietary Manager (CDM) during the inspection. The presence of food debris or dirt on nonfood contact surfaces, such as the microwave, can provide a suitable environment for the growth of microorganisms, which employees may inadvertently transfer to food. The expired food items and the lack of proper labeling on the bagels also pose a risk of foodborne illness. The dented can of soup further increases the risk of physical contamination. These failures had the potential to result in foodborne illness for the facility's 79 residents who consumed food prepared in the facility.
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What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.