Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Terrace View Care Center during CMS and state inspections, most recent first.
A resident who lacked decision-making capacity and had a physician order for a CPAP for obstructive sleep apnea used their own CPAP device in the facility, but staff failed to document this equipment on the admission inventory or on any Personal Inventory Update forms, contrary to facility policy. An LVN who handled both admission and discharge confirmed the CPAP was the resident’s own device and was sent home at discharge but acknowledged it was never itemized and could not recall the specific type of CPAP or other belongings returned. The DON stated staff were expected to record all personal items at admission, update, and discharge, yet the CPAP was absent from all inventory records, leading to a complaint from the resident’s representative that a different CPAP machine was received after discharge.
A resident's fall risk assessment was completed with multiple inaccuracies, including failure to document two recent falls and omission of several high-risk medications the resident was prescribed. Both an LVN and the DON confirmed these errors, noting that the resident's fall risk score would have been higher if the assessment had been accurate.
A resident's medical record was found to have inaccurate documentation of neuro check intervals following an unwitnessed fall. The neuro checks, which should have transitioned from one-hour to two-hour intervals, were recorded with a one-hour delay, as confirmed by both an LVN and the DON during review.
A CNA tied a bed sheet around a resident's waist and secured it to a wheelchair, restricting the resident's movement without a physician's order or documented medical necessity. The resident, who had moderate cognitive impairment but was able to make decisions, was found by a representative unable to move freely and reported feeling scared. Facility policy requires restraints only with proper orders and consent, and no such documentation was found. Staff interviews confirmed the restraint and lack of appropriate reporting or alternative interventions.
The facility did not conduct or document required interviews with a resident and a CNA after an allegation that the resident was tied to a wheelchair and physically abused. Although the facility interviewed family members, assessed the resident for injuries, and obtained a written statement from the CNA, there was no evidence of direct interviews with the alleged victim or perpetrator, leaving the investigation incomplete.
A resident with moderate cognitive impairment was not provided timely physician notification or neurological monitoring after being found tied to a wheelchair with a bedsheet and following an unwitnessed fall resulting in discoloration on the thigh. Facility staff delayed reporting these incidents to the physician and the resident's representative, and did not initiate required neurological assessments, contrary to facility policy.
A facility failed to ensure proper care for residents by not obtaining physician orders for a resident's personal glucose monitoring device, not following transfer orders for another resident with heart failure, and not timely addressing low oxygen saturation levels for a resident dependent on supplemental oxygen. These deficiencies were acknowledged by the facility's staff, highlighting lapses in monitoring and communication.
The facility failed to document baseline measurements for PICC lines in two residents and did not label a PIV site for another resident, leading to potential delays in identifying complications. The DON confirmed these deficiencies, indicating a lapse in following facility policies.
The facility failed to provide safe respiratory care for two residents by not adhering to cleaning guidelines for respiratory equipment. One resident's BiPAP machine and another's CPAP machine were not cleaned as per guidelines, and equipment was improperly stored, risking contamination. Staff interviews confirmed the lack of adherence to cleaning protocols.
A facility failed to administer dexamethasone to a resident as per the physician's order, which required the medication to be given every other day in the morning with breakfast. The LVN administered the medication late and not with breakfast, as confirmed by a medical record review and acknowledged by the DON.
The facility failed to properly monitor and document the side effects of psychotropic medications for three residents. One resident was not monitored for orthostatic hypotension as required, while another had inaccurate blood pressure monitoring and lacked documentation of non-pharmacological interventions. A third resident had identical blood pressure readings recorded for different positions, indicating improper monitoring. The DON confirmed these deficiencies.
The facility failed to follow food safety guidelines by having seven cups of apple juice and one cup of yogurt unlabeled and undated in the walk-in refrigerator. The DSS confirmed these items were prepared the previous night and should have been labeled according to the facility's policy. This affected all 55 residents receiving food from the kitchen. The Administrator and DON were informed and acknowledged the deficiency.
The facility's assessment was found lacking in comprehensive planning and stakeholder involvement, as it did not include input from direct care staff, residents, or their families. It also failed to address necessary resources for weekend care, staff recruitment and retention strategies, and a contingency plan for staffing needs. The Administrator confirmed these deficiencies and was unaware of the updated CMS requirements.
The facility failed to ensure proper infection control practices, as staff did not perform hand hygiene after removing PPE in a room under Novel Respiratory Precaution. Additionally, a CNA did not follow enhanced barrier precautions for a resident with a PICC line, despite posted signage. The DON and other staff acknowledged these deficiencies.
A facility failed to accurately code the MDS for a resident receiving heparin for DVT prophylaxis. The resident's medical record showed a physician's order for the anticoagulant, but the Admission MDS did not reflect its use. The MDS Coordinator confirmed the error, and the DON acknowledged the findings.
A facility failed to offer and administer a pneumococcal conjugate vaccine to a resident, despite policy requirements. The resident's immunization record showed receipt of the Pneumonia 23 vaccine, but not the conjugate vaccine. The IP confirmed the oversight, and the DON acknowledged the vaccine should have been offered again.
A resident in an LTC facility exhibited aggressive behavior towards two other residents, involving verbal and physical abuse. The incidents were witnessed by staff, but there was inadequate documentation and monitoring of the affected residents. The facility's policies on preventing abuse were not effectively implemented, leading to room transfers for the affected residents.
A facility failed to report abuse incidents timely, as required by policy. In one case, a resident hit another's foot, and the initial report was incomplete, with additional details provided 48 hours later. In another case, a resident yelled and raised a walker at another, causing fear, but the incident was reported five days late. Staff misjudged the situation as incompatibility, contributing to reporting delays.
A facility failed to investigate and monitor alleged abuse incidents involving a resident who exhibited aggressive behavior towards two other residents. In one incident, a resident hit another's foot, and in another, the same resident yelled and raised a walker threateningly. The facility did not interview all relevant staff or ensure daily monitoring by the SSD, as required by policy. These failures posed a risk for unaddressed resident abuse.
Failure to Document and Protect Resident’s CPAP as Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property by not documenting the resident's CPAP machine on any inventory forms during admission or discharge. The facility's Personal Property policy required that residents' personal belongings and clothing be inventoried and documented upon admission and updated as necessary. The resident, who lacked capacity to understand and make decisions per a history and physical dated 12/19/25, was admitted with personal belongings documented only as jackets and shoes on the Resident's Clothing and Possessions form. A physician's order dated 2/6/26 directed the use of a CPAP device for obstructive sleep apnea, and the responsible party later complained that when the resident was transported home, a different CPAP machine was received than the one originally provided to the facility. During interviews and record review, LVN 1 confirmed that the resident used their own CPAP machine in the facility and that she was responsible for both the admission and discharge processes, including completing the Resident's Clothing and Possessions form at discharge. LVN 1 stated that staff were expected to record belongings on admission and use a Personal Inventory Update form, which includes fields for add/delete, description, serial number, and quantity, whenever new items or equipment were brought in or removed, and to itemize belongings returned at discharge. However, there was no documentation of the CPAP machine on the admission inventory, no Personal Inventory Update form completed, and no record of the CPAP or other belongings sent with the resident at discharge. LVN 1 acknowledged that the CPAP machine was sent with the resident but could not recall the type of CPAP or other items sent, and the DON confirmed that staff were expected to record each personal item at admission, update, and discharge.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to accurately assess a resident for fall risk, as evidenced by multiple inaccuracies in the resident's Fall Risk Assessment. The assessment did not document two recent falls experienced by the resident—one unwitnessed fall in the facility and another in the community that resulted in severe injury, hospitalization, and subsequent admission to the facility. Additionally, the assessment failed to record several high-risk medications that the resident was prescribed, including a diuretic, antihypertensive, narcotic, and sedative. Both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed during interviews and medical record reviews that the Fall Risk Assessment contained these inaccuracies. They acknowledged that the resident's fall risk score would have been higher if the assessment had been completed accurately, reflecting the true number of falls and the medications taken. The facility's policy required staff to identify specific risks and causes to prevent falls, but this was not followed in this case.
Inaccurate Neuro Check Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate following an unwitnessed fall. According to the facility's policy, neuro assessments are required after any unwitnessed fall. Review of the resident's 72 Hour Neuro Check - List revealed that the time intervals between neuro checks were not accurately documented. Specifically, after the initial one-hour intervals, the transition to two-hour intervals was not correctly followed, resulting in all subsequent neuro check entries being delayed by one hour. During interviews and concurrent medical record reviews with both an LVN and the DON, it was confirmed that the neuro check documentation contained incorrect time entries. This inaccuracy in the resident's medical record meant that the required neuro assessments were not performed at the correct intervals as outlined in the facility's policy.
Resident Restrained with Bed Sheet Without Physician Order or Consent
Penalty
Summary
A certified nursing assistant (CNA) wrapped a bed sheet around a resident's waist and tied it behind the resident's wheelchair, preventing the resident from easily removing the material. This action was observed by the resident's representative, who found the resident in the dining room unable to move freely, with the CNA present and working on the computer. The resident reported feeling scared and called his son for help. The facility's policy and procedure (P&P) on the use of restraints specifies that restraints are only to be used for the safety and well-being of the resident, only after alternatives have been tried unsuccessfully, and only with a physician's order and consent. The P&P also defines a restraint as any device that the resident cannot remove in the same manner as applied, which restricts their ability to change position or place. Medical record review for the resident showed no documentation of a physician's order or any medical necessity for the use of physical restraints. The resident had a history of moderate cognitive impairment but was assessed as having the capacity to understand and make decisions. The CNA stated that the resident frequently got out of bed without assistance and was at risk of falling, and that the CNA needed to care for other residents. The CNA admitted to tying the resident to the wheelchair for safety reasons and acknowledged that this action was inappropriate and should have been reported to the charge nurse. Interviews with other staff confirmed the presence of the bed sheet tied around the resident in the wheelchair, though one licensed vocational nurse (LVN) did not check if the sheet was actually tied. The incident was reported to the charge nurse by both the resident's representative and the LVN. The director of nursing (DON) was informed and acknowledged the findings. There was no evidence that alternatives to restraint were attempted, nor was there documentation of required orders or consent for restraint use.
Failure to Interview Key Individuals in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident. According to the facility's own policy, all persons involved in an alleged abuse incident, including the alleged victim and perpetrator, must be interviewed as part of the investigation. However, when a resident's representative reported that the resident was found tied to a wheelchair with a bedsheet and alleged that a CNA had hit and kicked him, the facility did not conduct or document interviews with either the resident or the CNA involved. The investigation documentation showed that the facility interviewed the resident's family member, assessed the resident for injuries, and interviewed staff from the relevant shift and those who had provided care in the preceding 72 hours. Despite these steps, there was no evidence that the resident (the alleged victim) was interviewed directly, nor was there documentation of an interview with the CNA (the alleged perpetrator). The DON acknowledged that a written statement from the CNA was obtained, but this was not equivalent to an interview, and no documentation was provided to confirm an interview with the resident. The resident involved had moderate cognitive impairment and required maximum staff assistance for activities of daily living, but was determined to have the capacity to understand and make decisions. The failure to interview both the alleged victim and perpetrator was contrary to the facility's policy and left the investigation incomplete, as key firsthand accounts were not obtained or documented.
Failure to Notify Physician and Conduct Monitoring After Resident Incidents
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for one resident. The facility did not ensure timely physician notification when a resident's representative reported that the resident was tied to a wheelchair with a bedsheet and alleged that a CNA hit and kicked the resident. The incident was reported to the primary care clinician approximately seven hours after it was brought to the attention of facility staff, despite facility policy requiring prompt notification in urgent situations. The Director of Nursing confirmed that the physician notification was not timely. Additionally, the facility did not notify the physician or the resident's representative when the resident was found on the floor with purplish discoloration on the left thigh, following an unwitnessed fall. Facility policy required follow-up and monitoring, including neurological assessments after unwitnessed falls or injuries involving possible head trauma. However, neither neurological monitoring nor timely notifications were conducted or documented. Both LVNs involved in the incident confirmed that the physician and resident representative were not notified, and neurological evaluation was not initiated. The resident involved had a history of moderate cognitive impairment and required maximum staff assistance for activities of daily living. Medical records indicated the resident was capable of understanding and making decisions. The failures to notify the physician and representative, and to conduct appropriate monitoring after significant incidents, were verified by the Director of Nursing and were not in accordance with the facility's policies and procedures.
Deficiencies in Monitoring and Communication for Residents
Penalty
Summary
The facility failed to ensure proper care and management of a resident's blood glucose monitoring device. Resident 26, who has diabetes, was using a personal continuous blood sugar monitoring device, the Dexcom G6. Despite the resident managing the device independently, there was no physician's order or care plan documented for its use. The facility's staff, including the LVN and DON, acknowledged the absence of documentation and orders for the device, which could potentially lead to missed severe hypoglycemia or hyperglycemia occurrences. Another deficiency involved Resident 293, who was admitted with a diagnosis of Chronic Diastolic Heart Failure. The facility failed to follow the transfer orders from the acute care hospital, which included daily weight monitoring and a fluid restriction of 2,000 ml per day. There was no documentation that the attending physician was informed of these orders upon the resident's admission. Both the RN and DON confirmed the lack of communication and documentation regarding the transfer orders, which are crucial for managing the resident's condition. Resident 8, who was dependent on supplemental oxygen, experienced a deficiency in care when the facility failed to assess and notify the physician timely about low oxygen saturation levels. The resident's oxygen levels were documented below the physician-ordered threshold of 92% for several hours without any intervention or notification to the physician. The DON and RN acknowledged that the situation was not addressed until the resident's family member informed the staff, indicating a lapse in monitoring and communication regarding the resident's condition.
Deficiencies in IV Access Management
Penalty
Summary
The facility failed to provide necessary care and services for maintaining intravenous accesses for three residents. For two residents, the facility did not obtain and document baseline measurements of the PICC line external catheter and arm circumference upon admission. Resident 292, who had a PICC line on the left upper arm for IV antibiotic medication due to a blood infection, did not have these baseline measurements documented. Similarly, Resident 293, who had a PICC line on the right upper arm for IV antibiotic treatment following foot surgery, also lacked documented baseline measurements. Interviews with nursing staff confirmed the absence of these measurements, which are crucial for monitoring potential changes and complications. Additionally, the facility failed to label the PIV site for Resident 33 with the date, time, and initials of the licensed nurse who inserted it. Resident 33, who was receiving IV antibiotic treatment for a urinary tract infection, had a PIV site on the right arm that was not labeled, making it unclear when the PIV was inserted or when it needed to be changed. The nursing staff verified the absence of labeling and documentation in the medical record, which is necessary for ensuring timely care and communication among staff. The Director of Nursing (DON) acknowledged these deficiencies, confirming that the facility's policies and procedures were not followed. The lack of documentation and labeling could delay the identification of complications related to intravenous catheters, potentially impacting resident care.
Failure to Maintain Respiratory Equipment Cleanliness
Penalty
Summary
The facility failed to provide safe respiratory care services for two residents, Resident 8 and Resident 294, by not adhering to the manufacturer's guidelines and the facility's policies and procedures for cleaning and maintaining respiratory equipment. For Resident 8, the facility did not ensure that the non-invasive ventilator machine was cleaned according to the manufacturer's guidelines, nor did they ensure that the headgear and tubing were cleaned as per the facility's policies. Observations revealed that the nasal cannula tubing and BiPAP oxygen tubing were touching the ground, and there was no documentation of the cleaning of the BiPAP machine or the filter being checked. Resident 8, who was admitted with a diagnosis of COPD and required a non-invasive mechanical ventilator, had a care plan that failed to include interventions for the care and maintenance of the BiPAP device. Despite physician's orders for cleaning the headgear and tubing, there was no evidence that these were followed consistently. Interviews with staff, including an LVN and the DON, confirmed the lack of documentation and adherence to cleaning protocols, with the DON acknowledging the findings. For Resident 294, the facility did not ensure that the CPAP machine was cleaned according to the manufacturer's guidelines, and the mask and tubing were not stored properly when not in use. Observations showed the CPAP mask and tubing were placed on top of a drawer with the tubing touching the floor. The resident, who had a sleep disorder, was independent in using the CPAP machine, but there was no physician's order for cleaning the device weekly as directed by the user guide. Interviews with staff, including a CNA and an LVN, revealed that the licensed nurses were responsible for cleaning the CPAP machine, but there was no documentation of this being done, and the DON acknowledged the lack of compliance with the manufacturer's cleaning instructions.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for a resident. Specifically, a Licensed Vocational Nurse (LVN) did not administer dexamethasone, a steroid medication, to Resident 542 as per the physician's order. The physician's order required the medication to be given every other day in the morning with breakfast. However, during a medication administration observation, it was noted that the dexamethasone was administered late and not with breakfast as prescribed. The medical record review confirmed that the dexamethasone was scheduled to be administered at 0715 hours with breakfast, which was served at 0815 hours. The LVN acknowledged that the medication was administered late, not in accordance with the physician's order. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications and that proper monitoring and documentation were conducted. Resident 33 was prescribed sertraline for depression, with orders to monitor for side effects, including orthostatic hypotension. However, the facility did not document the blood pressure readings necessary to monitor for orthostatic hypotension, as confirmed by both RN 1 and the Director of Nursing (DON). Resident 36 was prescribed multiple psychotropic medications, including bupropion, desvenlafaxine, Depakote, and Seroquel, with specific orders to monitor for side effects and document non-pharmacological interventions. The facility failed to accurately monitor orthostatic blood pressures and did not document the implementation of non-pharmacological interventions for the resident's behavioral episodes. The DON confirmed that the facility did not follow the physician's orders for monitoring and documentation. Resident 27 was prescribed olanzapine, with orders to monitor orthostatic blood pressures weekly. The facility documented identical blood pressure readings for different positions, indicating improper monitoring. RN 1 and the DON acknowledged that the orthostatic blood pressure monitoring was not conducted correctly, which could have identified significant adverse reactions from the medication.
Unlabeled and Undated Food Items in Walk-in Refrigerator
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines as evidenced by the presence of seven cups of apple juice and one cup of yogurt that were unlabeled and undated inside the walk-in refrigerator. This oversight was identified during an initial tour of the kitchen, where the Dietary Services Supervisor (DSS) confirmed that the kitchen staff had prepared these items the previous night, and they should have been labeled and dated according to the facility's policy. The facility's policy, revised on January 1, 2018, mandates that any food removed from its original container must be properly labeled with the name of the food item and the date it was removed. The DSS acknowledged the failure to comply with this policy, which affected all 55 residents receiving food prepared in the kitchen. The Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Facility Assessment Lacks Comprehensive Planning and Stakeholder Involvement
Penalty
Summary
The facility failed to ensure that the Facility Assessment was comprehensive and up-to-date, as required by the revised CMS guidance. The assessment did not actively involve direct care staff, residents, their representatives, or family members in its development. Additionally, the assessment lacked details on the resources necessary to care for residents during weekends, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. These omissions were identified during an interview and document review with the Administrator, who confirmed the deficiencies and acknowledged a lack of awareness of the updated CMS requirements. The Administrator verified that the Facility Assessment was outdated, having been last updated on 6/6/24, and did not reflect the new CMS guidance effective from 8/8/24. The absence of active involvement from key stakeholders and the lack of comprehensive planning for staffing and resource allocation could potentially impact the facility's ability to meet residents' care needs. The Administrator admitted that the assessment did not include necessary resources for weekend care or strategies for staff recruitment and retention, nor did it have a contingency plan for staffing needs outside of emergency situations.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically in performing hand hygiene and following enhanced barrier precautions. Observations revealed that the Activity Assistant, CNA 7, and CNA 1 did not perform hand hygiene after removing personal protective equipment (PPE) upon exiting Room A, which was under Novel Respiratory Precaution. The Activity Assistant and CNAs acknowledged their failure to wash hands, which is a critical step in preventing the spread of infection as per the facility's policy. The Director of Staff Development (DSD) and the Administrator, along with the Director of Nursing (DON), were informed of these lapses and acknowledged the findings. Additionally, CNA 8 did not follow enhanced barrier precautions for Resident 294, who required such measures due to having a PICC line. Despite signage indicating the need for a gown and gloves during high-contact care, CNA 8 did not wear a gown while changing the resident's soiled briefs. CNA 8 was under the impression that the resident was no longer under isolation precautions, contrary to the posted signage and the resident's care plan. The DON confirmed that staff should be aware of and adhere to enhanced barrier precautions for residents like Resident 294.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident, which could potentially impact the resident's individualized care plan. The medical record review for the resident revealed a physician's order for heparin, an anticoagulant medication, to be administered subcutaneously every 12 hours for deep vein thrombosis (DVT) prophylaxis. However, the resident's Admission MDS did not reflect the use of this anticoagulant medication. During an interview and concurrent medical record review, the MDS Coordinator confirmed the incorrect coding of the MDS assessment. The Director of Nursing (DON) was informed and acknowledged the findings.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a pneumococcal immunization was offered and administered to a resident, identified as Resident 15, who was reviewed for pneumococcal immunization. The facility's policy and procedure, revised in October 2019, required that all residents be offered pneumococcal vaccines to prevent pneumococcal infections. However, a review of Resident 15's immunization record showed that while the resident received the Pneumonia 23 vaccine in June 2015, there was no documented evidence of the administration of the pneumococcal conjugate vaccine. During an interview and concurrent closed medical record review, the Infection Preventionist (IP) confirmed that the admitting nurse should have offered the PCV20 vaccine to Resident 15 upon admission, but this was not done. The Director of Nursing (DON) acknowledged the findings and stated that the pneumococcal conjugate vaccine should have been offered again to Resident 15. The oversight in offering the vaccine placed the resident at risk of acquiring pneumococcal infection.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents from verbal and physical abuse by another resident, specifically involving two residents. On one occasion, a resident was assisted by two nursing aide students when another resident angrily demanded the first resident to leave the room and subsequently hit the resident's right foot. This incident was witnessed by the nursing aide students, and the affected resident was assessed for injuries and emotional distress, leading to a room transfer. In another incident, a resident was verbally abused by the same aggressive resident, who yelled and used profanity in a foreign language. The aggressive resident also raised his walker as if to hit the other resident, causing fear and emotional distress. The affected resident expressed feeling unsafe and was subsequently transferred to another room. Despite these incidents, there was a lack of proper documentation and monitoring by the facility staff, as noted in interviews with the staff and residents. The facility's policies and procedures on preventing abuse were not effectively implemented, as evidenced by the repeated aggressive behavior of the resident and the inadequate response by the staff. The staff failed to document the incidents properly and did not monitor the affected residents after the incidents, which could have prevented further harm. The facility's Director of Nursing and other staff members were aware of the incidents but did not take sufficient action to address the aggressive behavior and ensure the safety of all residents.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. This failure was evident in two incidents involving residents. In the first incident, Resident 1 hit Resident 2's right foot, as witnessed by two nurse aide students. Although Resident 2 was assessed with no physical injuries and was monitored for emotional distress, the initial report filed to the California Department of Public Health (CDPH) was incomplete and lacked a description of the incident. The additional information was only provided 48 hours after the incident, which was not in compliance with the facility's policy requiring immediate reporting. In the second incident, Resident 1 yelled and cursed at Resident 3, raising his walker as if to hit him. Resident 3 reported feeling scared and was transferred to another room. Despite this, the incident was not reported to the appropriate agencies, including the CDPH, the ombudsman office, and law enforcement, until five days later. The facility's policy mandates that such incidents be reported immediately, within two hours if they involve abuse or result in serious bodily injury, or within 24 hours otherwise. The delay in reporting these incidents posed a risk for resident abuse not being identified and reported, potentially leading to continued abuse. Interviews with the Director of Nursing (DON) and other staff confirmed the findings. The DON acknowledged the incomplete initial report and the delay in providing additional information. Furthermore, the DON and other staff members did not perceive the second incident as verbal abuse, attributing it to incompatibility between the residents. This misjudgment contributed to the failure to report the incident in a timely manner, as required by the facility's policy.
Failure to Investigate and Monitor Alleged Abuse Incidents
Penalty
Summary
The facility failed to investigate an allegation of abuse according to its policies and procedures, and did not adequately monitor residents involved in the incidents. Resident 1 was involved in two separate incidents of aggression towards other residents. In the first incident, Resident 1 hit Resident 2's foot, which was witnessed by two nurse aide students. Although Resident 2 was assessed for physical injuries and monitored for emotional distress, the facility did not interview all staff members who had contact with the residents during the period of the alleged incident, as required by the facility's policy. Additionally, the facility did not ensure that the Social Services Director (SSD) visited Residents 1 and 2 daily for 72 hours as part of the investigation process. In the second incident, Resident 1 yelled and cursed at Resident 3, raising his walker as if to hit him. Resident 3 reported feeling scared and was subsequently transferred to another room. Despite this report, the facility did not conduct a further investigation into the incident. The facility's failure to investigate these incidents thoroughly posed a risk for resident abuse not being identified and addressed, especially in a facility with a vulnerable resident population. The facility's documentation and interviews with staff confirmed these deficiencies. The Director of Nursing (DON) and the SSD acknowledged the lack of proper investigation and monitoring. The facility's failure to adhere to its own policies and procedures for investigating and monitoring alleged abuse incidents highlights significant gaps in ensuring resident safety and compliance with regulatory standards.
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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 Fullerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenfield Care Center Of Fullerton, Llc | 0 mi | — | 15 | 0 |
| The Pavilion At Sunny Hills | 0 mi | — | 7 | 0 |
| St Elizabeth Healthcare Center | 0.4 mi | — | 25 | 0 |
| Park Vista At Morningside | 1.2 mi | — | 21 | 0 |
| St. Catherine Healthcare | 1.7 mi | — | 22 | 0 |
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