Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Pavilion On Pico Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with ESRD on hemodialysis, along with multiple comorbidities including DM2, COPD, heart failure, and HTN, had a missing post-dialysis evaluation in the medical record for one treatment date. During an interview and record review, an LVN confirmed that the post-dialysis evaluation form for that date was not completed, noting this could result in missed changes of condition or undocumented medications given during treatment. Review of the facility’s dialysis management policy showed that licensed nurses are required to complete both pre- and post-dialysis evaluations and maintain all dialysis-related documentation in the resident’s medical record, which was not done in this case.
A resident with multiple health conditions and mild cognitive impairment experienced inadequate discharge planning due to the facility's failure to conduct an IDT meeting and address the resident's personal requests. The Social Services Director's approach was perceived as rude, and the resident felt forced out. Staff acknowledged the resident's rights, but the facility did not follow its discharge policy, leading to ineffective planning.
A facility failed to provide necessary behavioral health care and services to a resident with major depressive disorder, who made unrealistic demands. The facility did not develop a care plan to address these behaviors, and the Social Services Director attempted to transfer the resident without proper discharge planning. Staff interviews revealed the facility could accommodate the resident's needs, but the lack of a person-centered care plan led to a deficiency in care.
A facility failed to provide adequate social services to a resident with multiple health conditions, including major depressive disorder. The resident's specific requests, such as early rising and daily laundry, were not accommodated, leading to psychosocial distress. The Social Services Director's approach was perceived as rude, and there was no proper discharge planning or understanding of resident rights, contributing to the deficiency.
Two residents experienced a delay in receiving their meals due to a mix-up with the food trays, leading to a failure in maintaining their dignity. The facility's usual process of serving all residents simultaneously was not followed, as confirmed by an LVN and the DON.
The facility did not follow its menu plan for residents on pureed diets, serving scrambled eggs instead of the prescribed Florentine torta. This substitution was not documented or approved by the Registered Dietitian, potentially compromising the nutritional intake of five residents. The Dietary Supervisor acknowledged the issue, noting the importance of adhering to standardized recipes to ensure adequate nutrition.
The facility failed to provide food in appropriate textures for residents on pureed and soft mechanical diets. Residents on a pureed diet received lumpy oatmeal, contrary to IDDSI standards, posing a choking risk. Additionally, residents on a soft mechanical diet were served bread with hard edges, which was against the facility's guidelines and also posed a choking hazard.
The facility was found to have multiple deficiencies in food storage and hygiene practices, including uncovered trash cans, improper hand hygiene, incorrect food storage, and unsanitary kitchen equipment. These issues could lead to cross-contamination and foodborne illnesses among residents.
The facility failed to maintain a clean garbage area, with debris such as masks and dog poop bags observed around the dumpster. Additionally, a dumpster was overflowing with trash and left uncovered due to a lack of Sunday trash pickup. This failure to adhere to cleanliness and waste management guidelines posed a potential infection risk to residents.
The facility failed to maintain sanitary conditions in the food services department, with six flies observed in the kitchen over two days. The Dietary Supervisor was unaware of the last pest control visit, and the pest control report only noted treatment in the exterior garbage area. This oversight potentially exposed 53 of 54 residents to foodborne illnesses.
A resident with hypothyroidism had an elevated TSH level, but the facility failed to document this change or notify the physician and resident's representative, as required by policy. The resident also refused a follow-up blood draw, and the physician was not informed of this refusal.
A resident with hypothyroidism had an elevated TSH level, but the facility failed to notify the physician as required by policy. Additionally, the resident refused a follow-up TSH test, and there was no documentation of physician notification. Interviews confirmed lapses in communication and documentation, contrary to facility policy.
A resident's LAL mattress was incorrectly set for a weight of 400 lbs instead of the resident's actual weight of 187 lbs, increasing the risk of pressure ulcer development. The resident, with conditions including diabetes and hemiplegia, required maximal assistance. The facility's policies and training materials indicated that mattress settings should be based on weight, but this was not followed, leading to the deficiency.
A resident with an indwelling urinary catheter did not receive appropriate care to prevent urinary tract infections due to the absence of a securement device and improper monitoring of catheter drainage. Despite the care plan's requirements, the catheter was not secured, leading to leakage and improper function. Facility staff, including a CNA and LVN, confirmed the catheter's mismanagement, and the resident was transferred to the hospital for further evaluation.
An LVN failed to follow a physician's order to hold Amlodipine for a resident with a pulse rate below the specified threshold. The resident's pulse was 58 BPM, but the LVN prepared the medication for administration until a surveyor intervened, highlighting a significant medication error.
The facility failed to maintain the correct temperature in a medication storage room, with the thermostat reading 90°F, above the acceptable range of 68-77°F. The fan, controlled by the light switch, was off when the light was off, causing the temperature rise. The temperature log was incomplete, missing an entry for one day, contrary to facility policy.
The facility was found non-compliant with room capacity regulations, as two rooms housed five residents each. Despite this, observations indicated sufficient space for resident movement and care provision. Staff and residents reported no concerns, and the administrator requested a waiver, asserting that care was not impeded.
The facility failed to meet federal room size requirements, with 17 out of 20 rooms not providing the mandated square footage per resident. Despite this, staff reported no concerns, and observations showed sufficient space for resident movement and care. A waiver request was submitted, but measurements confirmed non-compliance.
A facility failed to monitor and supervise residents with wandering behaviors, resulting in two elopement incidents. A resident with severe cognitive impairment left the facility unsupervised and was found at a previous address. Another resident, identified as high risk for elopement, left with a family member without triggering the wander-guard alarm. The Maintenance Supervisor could not explain the alarm failure, despite regular checks. Facility policies for wandering and elopement were not effectively implemented.
Incomplete Post-Dialysis Evaluation Documentation for Hemodialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-dialysis evaluation documentation for a resident who received hemodialysis. The resident was admitted with multiple diagnoses, including DM type 2, muscle weakness, COPD, heart failure, HTN, ESRD, and dependence on renal dialysis. An MDS assessment indicated the resident had intact cognition and required varying levels of assistance with ADLs, and that the resident received hemodialysis treatments. During a concurrent interview and record review with an LVN, the surveyor reviewed the resident’s pre- and post-dialysis evaluation records for March and found that the post-dialysis evaluation for a specific treatment date was missing from the medical record. The LVN confirmed that the post-dialysis evaluation for that date was not present in the record and acknowledged that this omission could result in missing changes of condition or medications given during the treatment. Review of the facility’s “Dialysis Management” policy, last reviewed on 6/20/25, showed that a pre- and post-dialysis evaluation was required to be completed by a licensed nurse and that all documentation concerning dialysis services and care of dialysis residents must be maintained in the resident’s medical record. The missing post-dialysis evaluation demonstrated that the facility did not follow its own policy and procedures for dialysis management and did not maintain a complete medical record for this resident.
Inadequate Discharge Planning and Resident Rights Violation
Penalty
Summary
The facility failed to adequately prepare and orient a resident for a safe and orderly discharge. The deficiency involved the lack of an Interdisciplinary Team (IDT) meeting to discuss the discharge planning for a resident with multiple health conditions, including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident required maximal assistance for activities of daily living and had mild cognitive impairment. Despite these needs, the facility did not conduct an IDT meeting to ensure a comprehensive discharge plan was in place. The discharge planning was initiated not based on the resident's health needs but rather on the resident's personal requests, such as wanting to get up early and requesting daily laundry services. The Social Services Director (SSD) indicated that the facility could not accommodate these demands and sought alternative facilities for the resident, which the resident declined. The SSD's approach to the resident was perceived as rude, and the resident felt as though they were being forced out of the facility. The resident expressed a desire to remain at the facility and was particular about their living arrangements. The facility's staff, including a Certified Nursing Assistant and a Registered Nurse, acknowledged the resident's rights to make choices about their care and daily routine. However, the SSD was unable to articulate the resident's rights regarding freedom of choice and did not follow the facility's policy on discharge and transfer, which requires a discharge summary and post-discharge plan of care. The facility's failure to honor the resident's rights to be treated with kindness, respect, and dignity contributed to the incomplete and ineffective discharge planning process.
Failure to Address Behavioral Health Needs and Implement Person-Centered Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident 1, who was admitted with diagnoses including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident's Minimum Data Set indicated mild cognitive impairment and a need for maximal assistance with activities of daily living. Despite these needs, the facility did not develop a care plan to address the resident's behavior of making unrealistic demands, as required by the facility's policy on Behavior/Psychotropic Drug Management. The resident's psychosocial note from a psychiatrist highlighted the need to address the resident's mood and emotional state, which influenced her behavior towards staff. However, the Social Services Director (SSD) failed to accommodate the resident's requests, such as being up by 6 a.m., having laundry done daily, and storing all belongings in her room. The SSD attempted to transfer the resident to another facility without conducting an interdisciplinary team meeting or understanding the facility's policy on discharge and transfer, which led to the resident feeling unwanted and neglected. Interviews with staff revealed that the facility could accommodate the resident's needs, but the SSD's approach and lack of understanding of residents' rights contributed to the deficiency. The Registered Nurse confirmed that the facility should not transfer the resident due to high demands and emphasized the importance of communicating with the resident to ensure she felt secure and respected. The facility's failure to implement a person-centered care plan and address the resident's behavioral health needs resulted in a deficiency in providing the highest practicable physical, mental, and psychosocial well-being for the resident.
Failure to Provide Adequate Social Services
Penalty
Summary
The facility failed to provide medically-related social services to Resident 1, who was admitted with diagnoses including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident's Minimum Data Set indicated mild cognitive impairment and a need for maximal assistance with activities of daily living. Despite these needs, the facility did not develop a care plan to address Resident 1's behavior of making unrealistic demands and requests, which contributed to the resident's psychosocial distress. The Social Services Director (SSD) failed to accommodate Resident 1's specific requests, such as being up by 6 a.m., having laundry done daily, and storing all belongings in her room. The SSD's approach to Resident 1 was perceived as rude, and the resident felt pressured to leave the facility. The SSD did not conduct an interdisciplinary team meeting for discharge planning and was unaware of the facility's policy on resident rights regarding freedom of choice. This lack of appropriate social services and communication contributed to Resident 1's distress. Interviews with staff, including a Certified Nursing Assistant and a Registered Nurse, revealed that Resident 1 was generally friendly and understood the limitations of the facility's services. However, the SSD's handling of the situation, including the suggestion of transferring Resident 1 to another facility without proper planning or understanding of resident rights, was inadequate. The facility's failure to address Resident 1's psychosocial needs and demands led to a deficiency in providing the highest practicable well-being for the resident.
Failure to Serve Meals Simultaneously
Penalty
Summary
The facility failed to maintain or enhance the dignity of two residents by not serving their meals at the same time as other residents in the dining room. Resident 2, who was admitted with chronic obstructive pulmonary disease, dysphagia, and type 2 diabetes, was observed waiting for her meal while other residents were served. The Minimum Data Set indicated that Resident 2 was severely cognitively impaired and required assistance with eating. During the observation, it was noted that the first food cart arrived, and seven residents received their meals while six others, including Resident 2, continued to wait. Licensed Vocational Nurse 3 acknowledged that the trays were not served simultaneously due to a mix-up and stated that this was not the usual process. The Director of Nursing also confirmed that the expectation was for all residents to receive their meals at the same time to prevent feelings of deprivation or neglect. The delay in serving meals was attributed to a communication issue with the kitchen, resulting in Resident 2 and Resident 42 receiving their meals later than others.
Failure to Follow Menu Plan for Pureed Diets
Penalty
Summary
The facility failed to adhere to its menu plan, which resulted in five out of 54 residents on pureed texture diets receiving scrambled eggs instead of the prescribed Florentine torta. This discrepancy was identified through observation, interviews, and record reviews. The facility's daily menu spreadsheet for residents on pureed diets indicated that they should receive a pureed Florentine torta, but scrambled eggs were served instead. The Dietary Supervisor acknowledged the substitution, stating that the Florentine torta recipe was not smooth when cooked, prompting the use of scrambled eggs for a smoother consistency. However, this change was not documented on the menu spreadsheet, and the Registered Dietitian was not informed of the substitution. The facility's Policies and Procedures for Menu Planning require that any menu changes be documented and approved by the Registered Dietitian or the Food and Nutrition Services Director. The failure to follow the standardized recipe and menu plan potentially compromised the residents' nutritional intake, as the substitution was not aligned with the planned nutritional content. The Dietary Supervisor admitted that not following the standardized recipe could lead to residents receiving inadequate nutrition, which could affect their overall health and well-being.
Failure to Provide Appropriate Food Textures for Residents
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs, specifically for residents on pureed and soft mechanical diets. Residents on a pureed International Dysphagia Standardization Initiative (IDDSI) level 4 diet, which requires food to be smooth and pudding-like, were served oatmeal with lumps. This was observed during a trayline inspection, and the Dietary Supervisor confirmed that the lumpy oatmeal posed a potential choking hazard. The facility's policy and procedures, as well as the diet manual, clearly stated that pureed diets should be smooth and free of lumps, aligning with IDDSI standards. Additionally, residents on a soft mechanical diet, intended for those with chewing or swallowing difficulties, received toasted bread with hard edges. The facility's standardized recipe for mechanical soft diets specified that breads should be soft and without hard crusts. The Dietary Supervisor acknowledged that the hard crusts on the bread were inappropriate for residents on this diet, as they could also pose a choking risk. The facility's diet manual reinforced that breads with hard crusts should be avoided for residents on a mechanical soft diet.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. The trash can in the handwashing sink room was not covered when not in use, which was against the facility's policy and could lead to the transport of bacteria. Staff members were observed not performing hand hygiene after touching potentially contaminated surfaces, such as the lids of garbage cans, and then handling clean trays and dishes. This lack of hand hygiene was contrary to the facility's policies and the Food Code 2022, which emphasize the importance of handwashing to prevent cross-contamination. In the kitchen, improper food storage practices were noted, with raw chicken stored above ground beef and cooked chicken stored below raw fish, violating the facility's food storage hierarchy. Additionally, several pieces of kitchen equipment and utensils were found to be in poor condition, with dust, rust, and debris present in refrigerators and freezers, and chipped and cracked trays and shelves. These conditions could lead to contamination and were not in compliance with the facility's policies or the Food Code 2022. Other issues included the improper handling of kitchenware, such as using cloths to dry steam table covers instead of air drying, and storing scoops in different orientations, which increased the risk of contamination. Staff food was also found stored in the resident's refrigerator, which could lead to mix-ups and potential allergic reactions for residents. These practices were not aligned with the facility's policies and posed a risk of foodborne illness to the residents.
Improper Garbage Disposal and Overflowing Dumpster
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. The garbage area was not maintained free from debris, including masks, dog poop bags, boxes, and dirt on the floor and surroundings of the dumpster. During an observation and interview with the Dietary Supervisor, it was noted that the trash area should be cleaned for infection control purposes. The Maintenance Director also confirmed the presence of debris and stated that it was coming from people walking by, emphasizing the need for cleanliness to prevent contamination. Additionally, one of the dumpsters was observed to be overflowing with trash, and its lid was not closed. This was noted during multiple observations, and the Maintenance Director acknowledged that the trash pickup schedule did not include Sundays, leading to the overflow. The facility's policies and procedures, as well as the Food Code 2022, require that garbage areas be kept clean and receptacles covered to prevent contamination and attract pests. The failure to adhere to these guidelines posed a potential risk of infection to the facility's residents.
Sanitation Deficiency in Food Services Due to Flies
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of six flies observed in the kitchen over a two-day period. Observations were made on different occasions, with flies seen around the preparation area, preparation table, and trayline. During interviews, the Dietary Supervisor acknowledged the presence of flies and expressed uncertainty about the last pest control visit, indicating a lack of awareness regarding pest management in the kitchen. The facility's Policy and Procedures on Pest Control, dated June 28, 2024, emphasized the importance of keeping the facility free from insects and other pests to ensure the health and safety of residents, staff, and visitors. However, a review of the pest control report from October 23, 2024, showed that treatment for large flies was only applied in the exterior garbage area, with no mention of the kitchen. This oversight potentially exposed 53 of 54 residents to foodborne illnesses due to the risk of consuming contaminated food.
Failure to Document and Notify Change in Resident's Condition
Penalty
Summary
The facility failed to document a significant change in condition for a resident, identified as Resident 2, in accordance with its policy and procedure. Resident 2, who was admitted with diagnoses including hypothyroidism, generalized muscle weakness, and hypertension, had a lab result indicating an elevated thyroid-stimulating hormone (TSH) level of 27.71 uIU/ml, which was significantly above the normal range. Despite this abnormal result, there was no documentation of a change of condition (COC) being completed, nor was there evidence that the attending physician or the resident's representative was notified of this change. Additionally, Resident 2 refused a follow-up blood draw for TSH, and again, there was no documented notification to the physician regarding this refusal. Interviews with the Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN) and the Director of Nursing (DON) confirmed that the facility's process for handling such situations was not followed. The facility's policy requires prompt notification of the physician and the resident's representative in the event of a significant change in condition, which was not adhered to in this case.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of abnormal laboratory test results for a resident, as required by their policy and procedure. The resident, who was admitted with diagnoses including hypothyroidism, had a thyroid-stimulating hormone (TSH) level of 27.71 uIU/ml, which is significantly above the normal range. Despite the facility's policy to notify the attending physician of abnormal lab results, there was no documented evidence that the physician or the resident's representative was informed of the elevated TSH level. Additionally, a change of condition (COC) was not completed, which is part of the facility's process for handling deviations from a resident's baseline condition. Furthermore, the resident refused a follow-up TSH laboratory draw that was ordered six weeks after the initial test. Again, there was no documentation indicating that the physician was notified of the resident's refusal to undergo the blood draw. Interviews with the Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN) and the Director of Nursing (DON) confirmed these lapses in communication and documentation. The facility's policy requires that lab results be promptly communicated to the physician to prevent delays in necessary interventions, but this protocol was not followed in this case.
Improper LAL Mattress Setting for Resident
Penalty
Summary
The facility failed to ensure that the Low Air Loss (LAL) mattress setting was appropriately set for a resident, identified as Resident 205, which could potentially lead to the redevelopment of pressure ulcers. Resident 205 was admitted with diagnoses including diabetes, hemiplegia, and generalized muscle weakness, and was cognitively intact but required maximal assistance for daily activities. During an observation, it was noted that the LAL mattress pump was set to a weight of 400 lbs, while the resident's actual weight was 187 lbs. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the incorrect setting could increase the risk of pressure ulcer development. The resident's care plan focused on skin integrity management and included interventions to prevent skin breakdown. The Director of Nursing (DON) confirmed that LAL mattress settings should be based on the resident's weight, and incorrect settings could lead to a high risk of skin breakdown. The facility's policy and procedures, as well as training materials, indicated that mattress settings should be adjusted according to the resident's weight to provide appropriate pressure reduction. However, the failure to adhere to these guidelines resulted in the deficiency observed during the survey.
Failure to Secure and Monitor Catheter Leads to Deficiency
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent urinary tract infections for Resident 16, who had an indwelling urinary catheter. The deficiency was identified when it was observed that the resident's suprapubic catheter did not have a securement device or anchor in place, which is necessary to prevent the catheter from being dislodged and causing trauma or infection. The resident's care plan required the catheter to be secured and assessed for proper placement and drainage, but these measures were not followed. As a result, the urine bag was not draining properly, and the resident's diaper was consistently wet, indicating leakage and improper catheter function. The resident, who was admitted with diagnoses including sepsis and acute kidney failure, was unable to understand and make decisions. Despite the care plan's instructions to assess urinary drainage and maintain proper catheter alignment, staff failed to ensure these interventions were implemented. Observations and interviews with facility staff, including a CNA and LVN, confirmed the catheter's improper management and the lack of a securement device. The Director of Nursing acknowledged the oversight, and the resident was eventually transferred to the hospital for catheter reinsertion and evaluation.
LVN Fails to Hold Amlodipine Despite Low Pulse Rate
Penalty
Summary
The Licensed Vocational Nurse (LVN) 4 failed to adhere to a physician's order regarding the administration of Amlodipine, a blood pressure medication, for a resident. The physician's order specified that Amlodipine should be held if the resident's systolic blood pressure was less than 100 or if the pulse rate was below 60 beats per minute (BPM). On the day of the incident, the resident's blood pressure was recorded at 144/73 mmHg, and the pulse rate was 58 BPM, which was below the specified threshold for administering the medication. Despite the resident's pulse rate being outside the parameters for safe administration, LVN 4 proceeded to prepare the Amlodipine for the resident. It was only after the surveyor intervened and prompted LVN 4 to review the blood pressure and pulse rate parameters that LVN 4 acknowledged the error and refrained from administering the medication. This oversight placed the resident at risk for a further decrease in heart rate, as the medication was not held as per the physician's directive.
Medication Storage Room Temperature Deficiency
Penalty
Summary
The facility failed to maintain the correct temperature in one of its medication storage rooms, which could potentially compromise the efficacy of the medications stored there. During an observation and interview, it was noted that the thermostat in the medication storage room indicated a temperature of 90 degrees Fahrenheit, which is above the acceptable range of 68 to 77 degrees Fahrenheit for controlled room temperature. The Registered Nurse Supervisor acknowledged the discrepancy in temperature. Further investigation revealed that the room's fan, which is controlled by the light switch, was not operating when the light was off, contributing to the elevated temperature. Additionally, a review of the room temperature log sheet showed that temperatures were recorded within the acceptable range from November 1 to November 15, but the entry for November 16 was left blank. The Licensed Vocational Nurse confirmed that the log should be completed daily. The facility's policy, revised in January 2018, requires that all medications be stored within specific temperature ranges as per the United States Pharmacopeia and the Centers for Disease Control guidelines. The failure to maintain the correct temperature and to consistently log the temperatures as per policy led to this deficiency.
Non-Compliance with Resident Room Capacity
Penalty
Summary
The facility was found to be non-compliant with the requirement that resident rooms hold no more than four residents. During an unannounced recertification survey, it was observed that two rooms housed five residents each. Despite the additional occupancy, the rooms were noted to have sufficient space for residents to move freely and for nursing staff to provide care. The residents had enough room to operate wheelchairs, walkers, and canes, and there was adequate space for bedside tables and other resident care equipment. Interviews with staff and residents revealed no concerns regarding the room sizes or the care provided. During a resident council meeting, attendees did not express any issues with their living space. The facility's administrator submitted a request for a waiver to allow more than four residents per room, citing that the room sizes did not impede resident care. The facility's client accommodation analysis confirmed the presence of five beds in the rooms in question.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, 17 out of 20 resident rooms did not meet the requirement of at least 80 square feet per resident. The rooms in question were designed to accommodate either two or three residents, but their sizes were insufficient, with two-bedroom units measuring only 140 square feet and three-bedroom units measuring 200 square feet. This deficiency was identified during a recertification survey, where it was noted that the rooms did not meet the federal standards of 160 square feet for two residents and 240 square feet for three residents. Despite the deficiency, staff interviews during the survey indicated no concerns regarding the room sizes, and observations showed that residents had ample space to move freely. The rooms were equipped with necessary furniture and equipment, allowing for freedom of movement and care provision. The facility had submitted a request for a room size waiver, arguing that the room sizes did not impede resident care, and the rooms provided adequate sunlight and ventilation. However, the measurements taken by the maintenance director confirmed the non-compliance with the required room dimensions.
Failure to Monitor and Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate monitoring and supervision of residents with wandering behaviors, leading to two incidents of elopement. Resident 1, who had severe cognitive impairment and was at high risk for elopement, left the facility unsupervised through the front reception area doors. The resident was later found at their previous address, 3.5 miles away. The staff, including a Certified Nurse Assistant (CNA), were unaware of the resident's whereabouts, and the wander-guard alarm system did not activate to alert staff of the resident's departure. Resident 2, who also had cognitive impairments and was identified as a high risk for elopement, left the facility with a family member for a doctor's appointment. Despite wearing a wander-guard bracelet, the alarm system failed to notify staff of the resident's exit. The Maintenance Supervisor, responsible for the wander-guard system, was unable to explain why the alarm did not trigger during these incidents, despite regular checks being conducted to ensure functionality. The facility's policies and procedures for wandering and elopement, as well as the signaling device, were not effectively implemented. The policies required verification of the signaling device's placement and functionality every shift and testing of the alarm functioning of exit doors weekly. However, these measures were insufficient in preventing the elopement of residents, as evidenced by the failure of the wander-guard system to activate during the incidents involving Residents 1 and 2.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Pico Terrace Healthcare & Wellness Centre Lp | 0.1 mi | — | 0 | 0 |
| Flower Villa, Inc | 0.6 mi | — | 2 | 0 |
| Miracle Mile Healthcare Center, Llc | 0.7 mi | — | 41 | 0 |
| Beverly Hills Rehabilitation Centre | 1 mi | — | 2 | 0 |
| Guardian Rehabilitation Hospital | 1.2 mi | — | 17 | 0 |
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