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CANHR "Violation of the Month" Archive


CNA Disregards NH Resident's Wishes and Strips Her of Her Dignity
A CNA violated a direct request from both a resident and her family member and her cut the resident's braided hair off, without her permission.
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Read the full citation HERE.


Glendale Nursing Home Dumps Resident at Train Station. Resident Found Six Days Later Naked in the Streets.
Griffith Park Healthcare Center, a one-star nursing home in Glendale was issued a citation after its administrator dropped off a mentally ill resident at a train station.
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Chronic Understaffing at Novato Healthcare Yields Two Weak Deficiencies
A complaint investigation found widespread concern from residents and staff about chronic understaffing at Novato Healthcare Center.
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04/2018 Bakersfield Nursing Home Shamelessly Dumps Two Residents
DPH has issued citations to The Rehabilitation Center of Bakersfield for dumping residents under horrible circumstances.
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03/2018 No Heat and Shivering Residents Nets Berkeley Nursing Home a Slap on the Wrist
Kyakameena Care Center, a Berkeley nursing home, lost its heat in December and went at least 45 days without heat through the dead of winter. Temperatures dipped into the low 60s and residents were observed bundled up in coats and blankets to ward off the cold.

08/2017 Fresno Nursing Home Sets Resident on Sidewalk, Calls 911, and Leaves
A 78 year old female resident was illegally evicted from the facility on 11/7/2016 when the staff called 911 and left her at the sidewalk of her former home when the police and fire departments arrived. 

07/2017 Plum Healthcare Nursing Home Cypress Ridge Sends Three Residents Packing
Cypress Ridge, a Monterey facility that is part of the Plum Healthcare nursing home chain, was recently cited for shipping three residents off to another nursing home over 200 miles away.

06/2017 Resident Tied to Wheelchair with a Sheet and Restraint Belt
On 7/9/2011 a 61 year old female resident diagnosed with dementia was tied to her wheelchair with a sheet and restraint belt for five hours at night by an employee of the facility.
04/2017 Resident Dies after Multiple Falls and Use of Chemical Restraints at Bethel Lutheran Home
In May of 2016, a female resident died due to injuries sustained from multiple consecutive falls at Bethel Lutheran Home in Selma, CA. The resident had dementia, and despite her high risk for falls, she was left unsupervised and allowed to fall while walking alone into her room on 5/16/16, resulting in multiple facial fractures, bleeding to the brain, and stitches on her scalp.
01/2017 Riverside Behavioral Healthcare Center Fined $2,000 for Suicide Deaths
Following the tragic deaths of two young residents who died from suicide, the Department of Public Health (DPH) issued an outrageously small fine of $2,000 to the Riverside nursing home where they had lived. On November 10, 2016, DPH issued a $2,000 Class B citation to the Riverside Behavioral Healthcare Center, a skilled nursing facility in Riverside.
08/2016 Bedsores, Wounds, and Necrotic Tissue in Mission Viejo RCFE
Using its new enhanced penalties (up to $15,000) for assisted living facilities for just the second time, Community Care Licensing has cited Golden Coast Senior Living #7, a Residential Care Facilities for the Elderly (RCFE) in Orange County, for tragically neglecting a resident in 2015.
07/2016 Kindred Nursing Home in San Francisco Cited for Illegally Evicting Residents on Medi-Cal
In March 2016, Kindred Transitional Care and Rehabilitation, Lawton – A Medicare and Medi-Cal certified nursing home in San Francisco – illegally transferred two residents and sought to transfer two other residents after their Medicare or other insurance coverage ended.
06/2016 Windsor Chico Creek Resident Dies From Lack of Oxygen
On 4/19/13, a resident died after the facility failed to keep the resident's oxygen level greater or equal to 90% per his physician's order. Multiple nurses failed to evaluate or report the resident's acute respiratory emergency and rapid deterioration to a physician and registered nurse (RN).
04/2016 Not Much Activity in Courtyard Health Care Center’s Activities
During a recent DPH survey at Courtyard Health Care Center in Davis, investigators compared the activities calendar with the actual activities taking place in the facility’s activity room. They found barely any residents participating in any activities and barely any life to the activities that were scheduled throughout the day.
03/2016 Dozens of Deficiencies for Clairemont Health in San Diego
A recent inspection of Clairemont Healthcare & Wellness Centre in San Diego found dozens of deficiencies, several of which caused harm to residents, ranging from resident mistreatment to unsafely dumping residents into assisted living facilities.
02/2016 Verdugo Valley Skilled Nursing & Wellness Centre Falsifies Records of Resident Who Did Not Have a Primary Physician for Over a Year
From June 2013 to June 2014, the Verdugo Valley Skilled Nursing & Wellness Centre willfully falsified a resident's medical records by documenting physician’s orders from a physician who did not give the orders or serve as the resident's physician. 
10/2015 Tujunga Nursing Home Treats Resident's Cries for Help by Piling on Psych Drugs
A female resident of Oakpark Healthcare Center died on 1/27/2013 from an infected and gangrenous foot wound.
08/2015 Male Residents Subjected to Multiple Instances of Sexual Abuse by CNAs
Three male residents were subjected to multiple observed instances of having their nipples rubbed and twisted by two CNAs.
06/2015 Gridley Healthcare & Wellness Centre Residents Subjected to Extreme Humiliation Via Videos Posted on Snapchat
Five certified nursing assistants (CNAs) were fired after taking and sharing illicit photos and videos of residents in a manner that humiliated and abused them.
04/2015 Resident at the Chino Valley Health Care Center Killed by Roommate with Psychiatric Problems
A 91 year old resident died on 12/4/2010, eleven days after being assaulted by his 46 year old roommate while in bed.
02/2015 Clairemont Healthcare Dumps Resident to her Trailer, Risking her Life
A Clairemont Healthcare & Wellness Centre resident who was totally dependent on staff for her care was dropped off by taxi to her trailer without a discharge plan, putting her life at risk.
01/2015 Petaluma Nursing Home Drugs Resident Into Oblivion. DPH Issues Citation (Over Two Years Later)
EmpRes PostAcute Rehabilitation was recently issued a Class A citation from the Dpeartment of Public Health for its part in heavily drugging a male resident with dementia. The resident was drugged with three antipsychotic drugs to restrain him from alleged physical aggression.
11/2014 Fresno Facility Ordered Shut-Down Over Horrible Conditions
Wish-I-Ah Skilled Nursing and Wellness Center, a nursing home in Auberry (Fresno County) was ordered shut-down by the state Department of Public Health after an investigation revealed terrible care and crumbling facilities.
09/2014 LA Nursing Home Hit with 68 Citations for Illegally Transferring Residents
The Western Convalescent Hospital, a skilled nursing facility located in Los Angeles, received 68 Class B citations for unlawfully transferring residents from the facility without proper notice in April 2014.
08/2014 Resident Illegally Pinned Down During Care at an RCFE
Nazareth Agua Caliente Villa, a Residential Care Facility for the Elderly in Sonoma, was cited for multiple regulatory violations after several staff members routinely restrained a resident by holding his hands and legs down while he was given personal care.
07/2014 Nursing Home Residents' Money Stolen by Facility Supervisor
A former business office manager (BOM) at Miravilla Care Center in Cherry Valley, CA stole a total of $38,115.49 from the trust funds of 45 residents during her employment between September 1, 2011 and August 17, 2013.
06/2014 Horrific Cut Scrotum Case Raises Big Questions
A resident was hospitalized with a cut and de-gloved (skin injury with shearing) scrotum.
05/2014 Nursing Home Goes to Casino and Gambles with a Resident's Life
A female resident who required an oxygen tank went on a trip to a casino. When her oxygen tank began to run low, none of the staff members knew how to attach the flow regulator to her new tank.
04/2014 Resident Dies After Facility Fails to Notify His Doctor of Critical Laboratory Results
On 4/19/13, a 75-year old resident died after Glenwood Gardens SNF, a skilled nursing facility in Bakersfield, failed to notify his doctor of critical laboratory results.
03/2014 Facility uses chemical restraints to sedate resident, who falls and breaks arm
A 78 year old male resident with a diagnosis of dementia and high risk of falls was receiving Ativan and Risperdal, two psychotropic drugs often used to sedate residents and that increase fall risks. On 9/18/12, the resident was given extra doses of Ativan to further chemically restrain him. That night, the resident fell and broke his arm.
02/2014 Facility Fails to Monitor Blood Thinning Medication, Resident Bleeds to Death
A female resident who was admitted on 8/15/12 was on Coumadin, a blood thinning medication requiring close monitoring to prevent severe bleeding episodes. A lab report showed the resident had blood clotting time six times the normal range.
12/2013 Palos Verdes Health Care Center Resident Sexually Assaulted by Nurse
On 10/3/13, the California Department of Public Health issued a $20,000 fine against the Palos Verdes Health Care Center in Lomita, California for failing to protect a resident from sexual abuse. A CNA reported the resident was crying and furious and that the nurse "looked guilty and his body language said it more."
09/2013 CPMC East Campus Resident Dies a Nightmare Death
An 88 year old resident admitted following hip surgery was noted to have a poor appetite and lost over 21 pounds in the two weeks after her admission. The resident's family indicated that the resident's stomach had grown so large it appeared she was pregnant.
08/2013 Hilltop Care Center Chains Resident to the Wall for Years
Hilltop Care Center, a nursing home in Hayward, was found to be regularly chaining a resident to the wall of his room during the day and then strapping him to his bed at night.
07/2013 Hayward Nursing Home Puts Resident in the Street - Literally
The California Department of Public Health (DPH) recently cited Driftwood Healthcare Center, a nursing home in Hayward, for violating the rights of a resident when it was found to have engaged in an illegal unplanned and dangerous late-night discharge.