Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citrus Heights Respiratory And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain and retain complete, accessible medical records and related documentation for numerous residents, particularly for periods before a change in ownership. Surveyors found that care plans, nursing progress notes, incident reports, five‑day investigations, grievance logs, and other records were missing or unavailable for residents involved in altercations, falls, and alleged financial misappropriation, even though federal assessment data confirmed those residents had been admitted and assessed at the facility. Staff acknowledged that records for residents admitted and discharged before the ownership change, and some records for current residents admitted earlier, were not available, and that incident and investigative records from those periods were also missing, contrary to facility policies requiring long‑term record retention and complete documentation of care and events.
Opioid medications were administered outside ordered pain parameters for three residents. MAR review showed oxycodone given when pain scores were below the physician-ordered ranges, including for a resident with severe cognitive impairment, a cognitively intact resident dependent on staff for all ADLs, and a resident with severe cognitive impairment and a femur fracture. Staff interviews confirmed nurses were expected to assess pain, follow the ordered parameters, and document the pain score at the time of administration; the DON stated the administrations for one resident did not meet expectations.
The facility failed to implement its abuse, neglect, and misappropriation policy by not maintaining investigation reports and contemporaneous clinical documentation for multiple allegations involving several residents. State records showed reports of lost personal property, financial misappropriation, resident‑to‑resident altercations, and alleged inappropriate sexual contact, often involving residents with dementia, traumatic brain injury, psychiatric disorders, and significant physical impairments. In numerous cases, the facility could not produce five‑day investigation reports, nursing progress notes, care plans, MDS assessments, or even basic identifying records for the timeframes of the incidents, and in some instances denied that an involved resident had ever lived there. Leadership acknowledged that records and investigation documents from before a change of ownership were not available, despite a stated retention expectation of ten years, resulting in noncompliance with the written abuse prevention and documentation policy.
Surveyors found that the facility lacked required clinical and investigation records for multiple residents involved in alleged abuse, resident‑to‑resident altercations, and misappropriation of property. For several residents with dementia, psychiatric disorders, traumatic brain injury, and other comorbidities, there were no care plans, nursing progress notes, MDS assessments, or 5‑day investigation reports covering the time of the alleged incidents. In some cases, the facility’s EHR contained no record of the alleged victim or alleged perpetrator, and staff stated that records for residents and incidents occurring before a change of ownership were not available, despite policies requiring long‑term retention of health records and abuse investigations and immediate reporting of all allegations to the Administrator and state and federal agencies.
The facility failed to thoroughly investigate and maintain documentation for multiple allegations of abuse, neglect, and misappropriation involving several residents with complex medical and psychiatric conditions. In numerous cases of alleged resident-to-resident altercations, loss or misuse of funds, and inappropriate sexual contact, the facility could not produce five-day investigation reports, contemporaneous nursing notes, care plans, or even basic clinical records for the residents involved. Facility leadership acknowledged that records and investigation reports from before a change of ownership were unavailable, despite policy and record-retention expectations, resulting in an inability to verify that required abuse investigations were completed in accordance with the facility’s abuse prevention policy.
A cognitively intact resident with multiple chronic conditions had a bottle of Zinc 50 mg labeled with their name and room number and a bag of menthol cough drops on the bedside table, which the resident reported having since admission. Review of the EHR, physician orders, and care plan showed no assessment or authorization for self-administration and no orders for zinc or cough drops. Staff, including a CNA, RN, unit manager, and DON, acknowledged that prescribed and OTC items such as vitamins and cough drops are considered medications and should not be kept at bedside without a self-administration order, assessment, documentation, and appropriate storage, none of which were in place for this resident.
Food items in the kitchen and nourishment refrigerators were found unlabeled, undated, and improperly stored. Observations showed opened whipped cream without visible dates, bacon and frozen burger patties left exposed in partially closed boxes, and multiple resident food items in nourishment fridges with no room numbers or dates. Staff also found staff lunch items mixed with resident food, unidentifiable food in containers, and dirty refrigerator surfaces with food residue.
A CNA handled a resident and then delivered a lunch tray without performing hand hygiene, and the unit lacked visible hand sanitizer dispensers. In a separate event, a housekeeper cleaned a room previously under contact precautions for C. diff while wearing gloves only, with no isolation signage posted outside the room. The resident had diagnoses including C. diff, renal dialysis dependence, and acute respiratory failure with hypoxia, and staff described the room as having been deep cleaned the prior night, though no documentation was available.
A resident with severe cognitive impairment and diagnoses including a left femur fracture and encephalopathy was documented as verbally consenting to influenza, pneumococcal, and COVID-19 vaccines, but the pneumococcal vaccine was not offered, no MD order was present, and no MAR/TAR evidence showed it was given during the admission. The Infection Preventionist later stated this was a nursing error and that she had not been informed the resident needed the pneumococcal vaccine.
The facility failed to maintain required medical records for a resident admitted in 2022 who had moderate cognitive impairment and multiple chronic conditions, including ESRD, diabetes, seizure disorder, and mental health diagnoses. When surveyors requested the resident’s chart, including the facesheet, diagnoses, physician orders, MAR/TAR, progress notes, care plan, census information, and self-reports, facility staff reported they could not provide any records from before a change in ownership because they had no access to the prior EMR system after the previous owner stopped paying for it. The Medical Records Director and DON acknowledged that records are required to be retained for 10 years, and facility policies on medical record content and record retention also required long-term maintenance of resident records and investigations, which was not achieved due to the lack of access to historical records.
A resident did not receive prescribed antibiotics for eight days due to the facility's failure to obtain the medications as ordered. The resident, with a history of severe sepsis, was discharged from the hospital with orders for cefiderocol and gentamicin. Despite attempts to resolve the issue, including contacting the pharmacy and notifying the DON, the medications were not administered until eight days later, highlighting a breakdown in the facility's medication administration process.
A facility failed to update its infection control policies in line with CDC guidelines, leading to improper use of PPE during wound care. A resident with a pressure ulcer did not receive care with the recommended gown and gloves, as the facility's policy only required gowns for stage III or greater wounds. The DON, acting as the Infection Preventionist, lacked proper certification, and the facility's policy was outdated.
Failure to Maintain and Retain Required Resident Medical Records and Incident Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and readily accessible medical records and related documentation for multiple residents, as required by professional standards and the facility’s own record retention policies. During the survey, records dated prior to March 1, 2025 were largely unavailable in the electronic health record (EHR) system, despite evidence from State Authority (S.A.) MDS submissions that numerous residents had been admitted and resided in the facility before that date. Surveyors requested care plans, nursing progress notes, five‑day investigation reports, and other clinical documentation for sampled residents, but the facility repeatedly stated it was not in possession of these records. For several residents involved in alleged incidents or complaints, including resident‑to‑resident altercations, falls, and alleged misappropriation of funds, the facility could not produce contemporaneous care plans, nursing progress notes, incident reports, or five‑day investigative reports. Examples included a resident‑to‑resident altercation where one resident’s earliest care plan and nursing notes in the EHR began approximately a year after the reported event, and another resident involved in the same altercation had no clinical record in the EHR at all. In other cases, residents with documented admissions in the S.A. MDS had no EHR record, no care plans, and no nursing progress notes corresponding to the timeframes of reported incidents or allegations. The facility also reported that it did not possess grievance logs for entire prior years and for early months of a subsequent year, despite a record request for those periods. Additional discrepancies were identified when the facility asserted that certain residents had never resided there, while iQIES data and MDS submissions showed those residents had been admitted with various diagnoses and documented BIMS scores. For multiple such residents, there was no evidence of any medical record in the facility’s EHR. Interviews with the Medical Records Supervisor and the Administrator confirmed that there were no medical records available for residents admitted and discharged prior to March 1, 2025, and that some records for current residents admitted before that date might also be missing. They acknowledged that incident reports and five‑day investigations prior to the ownership change were not available, and that they had no access to paper records from the previous owner. Facility policies reviewed by surveyors required maintaining resident medical records for 10 years and investigations for 5 years, and required documentation to provide a complete account of residents’ care, treatment, and progress, which was not met in these cases. The deficiency also encompassed the facility’s inability to provide complete MDS, care plans, and progress notes for specific timeframes related to allegations of resident‑to‑resident aggression, falls, and financial misappropriation. For example, for a resident who reported being attacked by another resident, the earliest MDS and care plan on record did not cover the period of the alleged event, and requested progress notes and care plans for the months surrounding the allegation were not available. For another resident with an alleged misappropriation of benefit funds, no records could be located in the EHR, and the facility stated it did not possess information for incidents occurring before March 1, 2025. Across these cases, the survey findings consistently showed that required clinical and investigative documentation was missing or incomplete for residents whose presence and clinical status at the facility were documented in federal assessment systems, demonstrating a systemic failure to retain and maintain medical records and related documents in accordance with policy and accepted standards. Interviews further clarified that the lack of records was linked to a change of ownership on March 1, 2025, after which the new Administrator reported having no access to prior physical records, including medical records, incident reports, and five‑day investigations. The Medical Records Supervisor, who assumed her role months after the ownership change, stated she had no knowledge of what the previous owners had done with the paper records and confirmed that no paper copies of incident reports or five‑day investigations for alleged incidents were available. Both staff members acknowledged that the expectation was to maintain resident medical records for 10 years and investigations for 5 years, and that upon transfer of ownership, the facility should have had access to all resident records within the required retention timeframe. Despite these expectations and written policies, the facility did not have the historical records necessary to provide a complete account of residents’ care and prior incidents. The surveyors’ review of facility policies titled “Documentation and Charting” and “Record Retention Schedule” showed that the facility’s own standards required a complete account of residents’ care, treatment, response, signs and symptoms, and progress, and mandated retention of resident medical records for 10 years and investigations for 5 years. The absence of records for numerous residents, including those with documented admissions and MDS assessments, and the lack of incident reports, five‑day investigations, and grievance logs for multiple years, directly conflicted with these policies. The facility’s inability to produce these records during the survey, despite multiple requests and the presence of corresponding data in iQIES and S.A. MDS, formed the basis of the cited deficiency for failure to safeguard and maintain complete medical records in accordance with accepted professional standards. The Administrator and Medical Records Supervisor both acknowledged during interviews that the facility did not have medical records for residents admitted and discharged prior to the ownership change, and that some records for current residents admitted before that date were also missing. They also confirmed that incident reports and five‑day investigations prior to the change of ownership were not available, and that they could not reach the previous owners, who had relocated to another country. These statements, combined with the documented absence of records in the EHR and the facility’s written responses to record requests, demonstrated that the facility lacked the required historical documentation for a significant number of residents and events, leading to the cited deficiency. The survey findings also highlighted that, despite the facility’s dispute of the citation, the objective evidence from iQIES and S.A. MDS data showed that residents for whom the facility claimed no records or no residency had, in fact, been admitted and assessed at the facility. The lack of corresponding medical records, care plans, nursing notes, incident reports, five‑day investigations, and grievance logs for these residents and timeframes was inconsistent with both regulatory expectations and the facility’s own policies. This systemic absence of historical resident documentation and investigative records formed the core of the deficiency related to safeguarding and maintaining resident‑identifiable information and medical records. Overall, the deficiency was based on the facility’s failure to ensure the presence of complete and readily accessible medical records for a large portion of the sampled residents, including those involved in reported incidents and complaints, and its failure to retain required records such as incident reports, five‑day investigations, and grievance logs for the mandated retention periods. The surveyors’ observations, record reviews, and staff interviews collectively demonstrated that the facility did not have the necessary historical documentation to meet accepted professional standards for medical record maintenance and retention.
Opioid medications administered outside ordered pain parameters
Penalty
Summary
The facility failed to ensure that three residents received opioid medications according to physician orders. Review of clinical records, MARs, care plans, and staff interviews showed that oxycodone was administered to Residents #4, #50, and #90 when the documented pain scores were outside the ordered parameters. The deficiency involved medication administration for residents with pain-related diagnoses and included both scheduled care plan interventions and PRN opioid orders. Resident #4 was admitted with diagnoses including nontraumatic subdural hemorrhage, extradural and subdural abscess, and cognitive communication deficit. The resident had a BIMS score of 0, indicating severe cognitive impairment, and required moderate to maximum assistance with ADLs. The care plan identified opioid use for pain in the head and abdomen and directed staff to administer the opioid as prescribed and follow the pain scale. The physician ordered oxycodone HCl 5 mg every 6 hours as needed for pain rated 4 through 10. The MAR showed multiple administrations when the recorded pain scores were 0 or 1, including several doses in February and March 2026. Resident #50 was re-admitted with diagnoses including lymphedema, generalized muscle weakness, and hereditary and idiopathic neuropathy. The resident had a BIMS score of 14 and was dependent on staff for all personal cares and ADLs. The care plan identified opioid use for pain in the right thigh and knee and directed staff to administer opioid medications. The physician ordered oxycodone HCl 10 mg every 4 hours as needed for pain rated 5 through 10. The MAR showed administrations when the recorded pain scores were 0, 1, or 2, including multiple doses in February and March 2026. Resident #90 was admitted with diagnoses including a left femur neck fracture, encephalopathy, and generalized muscle weakness. The resident had a BIMS score of 3 and required maximum assistance or was fully dependent for personal care and ADLs. The care plan directed staff to administer opioid medications as prescribed and to follow the pain scale. The physician ordered oxycodone HCl 5 mg, one tablet every 6 hours as needed for pain rated 4 through 6, and oxycodone HCl 5 mg, two tablets every 6 hours as needed for pain rated 7 through 10. The MAR showed administrations of one tablet when the pain score was 3 or 1, and two tablets when the pain score was 0 or 1. Staff interviews confirmed that nurses were expected to assess pain, follow ordered parameters, and document the pain score at the time of administration. The DON stated that medications should not be administered outside of parameters and that documentation and administration for Resident #4 did not meet expectations.
Failure to Implement Abuse and Misappropriation Investigation Policy and Maintain Required Records
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and misappropriation policy by not conducting or maintaining thorough investigations and related clinical documentation for multiple allegations of abuse, neglect, and theft involving 11 residents. State Agency (SA) records showed that various incidents, including misappropriation of property, resident‑to‑resident altercations, and alleged sexual contact, had been reported and that the facility had indicated investigations were conducted. However, during the survey, the facility was unable to produce investigation reports, five‑day reports, or contemporaneous clinical documentation such as nursing progress notes, care plans, and Minimum Data Set (MDS) assessments for the timeframes of the allegations, despite policy requirements to identify, document, and investigate abuse, neglect, exploitation, and misappropriation. For one resident who reported loss of personal property allegedly involving a nurse aide, SA records indicated the facility conducted an internal investigation immediately after the incident, but the facility could not provide the investigation report and denied that the resident had ever resided there, even though SA MDS data showed an admission. Another resident with dementia, bipolar disorder, anxiety, depression, and mobility issues had an allegation of misappropriation by a payee; yet the EHR contained no care plan, nursing notes, or task records for the relevant month, and the facility stated it did not possess any supporting documentation. In a documented resident‑to‑resident altercation where one resident struck another’s hand in the dining room, the facility reported that staff separated the residents and conducted an investigation, but later could not produce a five‑day report, a face sheet for one of the residents, or nursing documentation for the time of the incident. Additional SA‑reported resident‑to‑resident altercations and misappropriation allegations similarly lacked corresponding facility records. In one case, a resident with traumatic brain injury, anxiety, and depression was reportedly struck on the shoulder by another resident with schizoaffective disorder, traumatic brain injury, and multiple psychiatric diagnoses, but there were no nursing progress notes for either resident for the period of the incident and no five‑day investigation report. Another resident with hypertension, prior transient ischemic attack, and adjustment disorder had an alleged misappropriation of financial resources, yet there was no care plan for the year of the allegation, no progress notes for that period, and no investigation report. A resident with traumatic brain injury, legal blindness, seizures, and serious mental illness reported being attacked by another resident, but the facility lacked MDS, care plans, and progress notes for the months surrounding the allegation. Further, an allegation of inappropriate sexual contact between roommates was reported, but the facility’s EHR contained no record for the alleged perpetrator, and for the alleged victim there was no MDS or care plan on or before the date of the incident and no nursing notes until much later. Another resident who discovered that insurance catalog benefits had been nearly depleted was not found in the EHR at all, and the facility stated it did not have records for residents or incidents prior to a change of ownership. The Administrator reported that the facility did not have access to medical records, five‑day investigation reports, or self‑reported incidents from before the ownership change, and the Medical Records Supervisor stated that such records should be retained for ten years but that no paper records existed for residents prior to that date. These inactions and missing records demonstrate that the facility did not follow its abuse prevention policy requiring immediate reporting, protection of alleged victims, and thorough identification and documentation of abuse, neglect, exploitation, and misappropriation. The facility’s written policy on abuse prevention and prohibition stated that each resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that staff with knowledge of actual or potential violations must report them immediately to the Administrator. The policy further required the facility to identify and document abuse, neglect, exploitation, and misappropriation, including through assessments and review of occurrences, patterns, and trends such as resident‑to‑resident altercations, and to respond immediately to protect alleged victims and preserve the integrity of investigations, including examination of alleged victims for signs of injury via physical and/or psychosocial assessment. The absence of investigation reports, contemporaneous clinical documentation, and retained records for the cited residents and incidents shows that these policy requirements were not implemented for the 11 sampled residents associated with the SA‑reported allegations.
Missing Abuse and Misappropriation Investigation Records After Ownership Change
Penalty
Summary
The deficiency involves the facility’s failure to ensure that allegations of abuse, neglect, and misappropriation of resident property were properly documented and that related investigation records were available, as required by policy and regulation. Surveyors found that for 11 sampled residents, there were missing clinical records, care plans, nursing progress notes, and investigation reports associated with reported or alleged incidents. The facility repeatedly stated it was not in possession of requested records, including 5‑day investigation reports and self‑reports, for events that had been reported to the State Agency (SA) or were alleged by residents. One resident was reportedly involved in an altercation with a nurse aide regarding loss of personal property, but the facility could not produce an investigation report or any clinical records for that individual and asserted that the resident had never resided there. Another resident had an allegation of misappropriation of funds by a payee, yet there was no care plan, nursing progress notes, or task documentation for the relevant time period in the EHR, and the facility reported it did not have those documents. In a separate resident‑to‑resident altercation, one resident with dementia and multiple psychiatric diagnoses remained in the facility, but the earliest nursing notes in the EHR were dated long after the alleged incident, and the facility could not provide the 5‑day report or records for the other resident allegedly involved, stating it did not possess those records. Additional SA‑reported resident‑to‑resident altercations and misappropriation allegations were also not supported by contemporaneous documentation in the facility’s records. For two residents involved in a reported altercation, nursing progress notes only began more than a year after the incident, and no investigation report was available. For a resident with hypertension and cerebrovascular history, there was no care plan for the year of a reported misappropriation allegation and no progress notes or 5‑day report for the months surrounding the event. A resident with traumatic brain injury and psychiatric diagnoses reported being attacked by another resident, but the MDS and care plan for the relevant period were missing, and the facility could not provide requested progress notes or care plans for the months before and after the alleged event. In another allegation, a resident reported that his roommate fondled his genitals; however, there was no documentation for the alleged roommate in the EHR, and the facility stated that person had never resided there. The resident’s own MDS and care plan did not cover the date of the alleged incident, and the earliest care plan and nursing notes were dated more than two years later. A separate resident who alleged misuse of insurance catalog benefits could not be located in the EHR at all, and the facility stated it did not have records if the resident or incident pre‑dated a change of ownership. The Medical Records Supervisor stated that medical records and incident/5‑day investigation reports should be retained for 10 years, and the Administrator confirmed there were no medical records or access to medical records, including 5‑day investigations and self‑reports, for residents prior to the change of ownership date. Facility policies required retention of resident health records for 10 years and facility investigations for 5 years, and required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and appropriate state and federal agencies, but the facility lacked the records to demonstrate compliance for the cited residents and events.
Failure to Investigate and Document Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and maintain documentation for multiple allegations of abuse, neglect, and misappropriation of property as required by its own abuse prevention policy. For one resident who allegedly accused a nurse aide of loss of personal property, state agency records showed the resident had been admitted to the facility, but the facility denied the resident had ever resided there and could not provide a five-day investigation report or any clinical records. In another case involving an alleged misappropriation of funds by a resident’s payee, the facility’s EHR contained no care plan, nursing progress notes, or task records for the relevant time period, and the facility stated it did not possess the requested records, preventing confirmation that the allegation was investigated. Additional deficiencies were identified in several resident-to-resident altercations and other abuse-related complaints. In one incident, a resident reportedly struck another resident’s hand in the dining room; staff stated the residents were separated and an investigation was conducted, but the facility could not produce a five-day investigation report or nursing documentation for the time of the incident. One of the involved residents did not appear in the EHR at all, and the facility reported having no documentation for that resident. In another altercation, a resident was observed striking another resident on the shoulder, but there were no nursing progress notes for either resident for the time frame of the incident, and the facility could not provide an investigation report. Further, the facility lacked documentation for allegations of misappropriation of financial resources, physical attacks by other residents, and inappropriate sexual contact between roommates. For one resident alleging misappropriation of financial resources, there was no care plan for the year of the allegation and no nursing progress notes until nearly two years later, and the facility could not provide investigation reports or contemporaneous records. For another resident who reported being physically attacked by another resident, the MDS and care plans for the relevant period were unavailable. In a complaint of inappropriate sexual contact, the alleged perpetrator did not appear in the EHR and the facility stated that person had never resided there, while the complainant’s MDS, care plan, and nursing notes for the time of the allegation were missing. In an additional case of alleged misuse of insurance benefits, the facility had no records for the resident and stated it did not possess information for residents or incidents prior to a change of ownership. Interviews with the Administrator and the Medical Records Supervisor confirmed that the facility did not have access to medical records, incident reports, or five-day investigation reports for residents prior to a change of ownership, despite the Medical Records Supervisor stating that such records should be retained for ten years following discharge. Both acknowledged that no paper records existed for residents prior to the ownership change and that this absence resulted in a lack of resident history and incomplete understanding of residents’ needs. Review of the facility’s abuse prevention policy showed that all allegations of abuse, neglect, misappropriation, and exploitation were to be promptly reported, thoroughly investigated, and fully documented, but the facility’s inability to produce investigation reports and contemporaneous clinical documentation for the cited residents demonstrated noncompliance with this policy.
Unauthorized Medications Kept at Bedside Without Self-Administration Assessment or Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored and administered according to policy for one cognitively intact resident. The resident was admitted with multiple diagnoses including major depressive disorder, anxiety disorder, neuromuscular bladder dysfunction, ventilator dependence, morbid obesity, obstructive sleep apnea, polyneuropathy, chronic diastolic CHF, chronic respiratory failure with hypoxia, and bradycardia. A quarterly MDS showed a BIMS score of 15, indicating intact cognition. Review of the physician’s orders, care plan, and EHR showed no evidence of an order authorizing the resident to self-administer medications and no documented assessment for self-administration, despite facility policy requiring IDT assessment and documentation when a resident participates in self-administration of medications. During an observation in the resident’s room, surveyors noted a bottle of Zinc 50 mg and a bag of Halls cherry-flavored menthol cough drops on the bedside table. The bottle of zinc was labeled with the resident’s name and room number. The resident stated that both items had been at the bedside since admission. There was no evidence in the EHR of any physician order for oral zinc or for cough drops for this resident. The presence of these items at bedside occurred without the required assessment, orders, or care plan entries for self-administration, and without secure storage as required for medications. Interviews with staff confirmed that the zinc and cough drops were considered medications that should not be kept at bedside without a self-administration order. A CNA stated that medications include prescribed and OTC items, including vitamins, and that residents cannot have medications at bedside unless authorized to self-administer; she acknowledged that zinc and cough drops at the bedside should not have been there. An RN similarly stated that medications can be prescribed or OTC and include oral, topical, inhaled, or injected forms, and confirmed there were no orders for zinc or cough drops for this resident. The unit manager and DON both stated that residents may not have medications at bedside unless assessed and authorized for self-administration, with documentation and appropriate storage, which had not occurred for this resident.
Food Items Not Labeled, Dated, or Stored Properly
Penalty
Summary
The facility failed to ensure food items in the kitchen and nourishment refrigerators were labeled, dated, and stored correctly. During a kitchen observation with the Dietary Supervisor, six piping bags of whipped cream were found in the refrigerator, including one opened bag with no visible dates. Also observed were a partially closed cardboard box holding bacon strips in a clear plastic bag in the refrigerator and a partially closed cardboard box containing a clear plastic bag of frozen burger patties in the freezer, both open and exposed to air. In the nourishment refrigerator on Station 1, multiple items were observed with no room number or dates, including Trader Joe's buffalo chicken dip, a small container of Fritos bean dip, a black container of white rice, a reused sliced peaches jar filled with soup, and a Hillshire Farms roasted turkey breast deli meat container filled with bologna slices. The refrigerator also had a brown crusted and sticky substance on the floor, a white sticky substance on the shelving, and small brown food crumbs in the freezer. In the nourishment refrigerator on Station 4, two lunch totes had no names, labels, or dates, a glass container with a pink lid held unidentifiable food, and a Redbull energy drink had no names, labels, or dates. Staff interviews confirmed that the observed food items were not acceptable practice, that staff lunches should be stored elsewhere, and that food items were expected to have received, opened, and discard dates.
Hand Hygiene and Contact Isolation PPE Lapses
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control practices were followed for hand hygiene and for the use of PPE when entering and cleaning a contact isolation room. During an observation in the locked unit dining room, a CNA moved a basket of laundry, redirected a resident by placing a hand on the resident’s shoulder, and then immediately handled and delivered a lunch tray without performing hand hygiene between resident contact and contact with the food tray. During the same observation period, there were no hand sanitizer dispensers on the hallway walls, in resident rooms, or at the nurse’s station on the unit. The CNA stated she was not used to working on that unit and was reminded by another staff member to perform hand hygiene. Another CNA confirmed there were no hand sanitizer dispensers on the unit and stated that each staff member carried a personal hand sanitizer bottle. Resident #84 was admitted with diagnoses including enterocolitis due to C. diff, dependence on renal dialysis, and acute respiratory failure with hypoxia. A physician order dated February 27, 2026, directed contact precautions for C. diff, with all therapies, treatment, cares, and meals in a single occupancy room every shift. A later physician order dated March 9, 2026, prescribed strict contact isolation precautions related to C. diff and directed staff to wear a gown and gloves and to wash with soap and water before leaving the room. When the resident’s room was observed being cleaned, there was no signage outside the room identifying the transmission-based precaution status or the occupant of the room. A housekeeper was observed cleaning the floor and removing trash while wearing gloves only and no other PPE. The housekeeper stated the resident had been transferred to another room and that she was cleaning the room because a new admission was being assigned later that day. She stated there had been no sign posted outside the room before she entered, although she knew the room had been a transmission-based precaution room the day before. The housekeeping supervisor stated staff should wear the PPE indicated on the signage outside the door, but was unaware how this was communicated if nursing staff removed signs without informing housekeeping. The ADON/IP stated the room had been deep cleaned the night prior by another nurse, but she was unable to provide documentation confirming that the room was deep cleaned.
Missed Pneumococcal Vaccination
Penalty
Summary
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations resulted in one resident not receiving a pneumococcal vaccination during the current admission. The resident was admitted with diagnoses including fracture of the left femur, encephalopathy, and need for assistance with personal care. A consent form dated January 2, 2026 documented verbal consent for influenza, pneumococcal, and COVID-19 vaccination, and the form was signed by two nurses, including the Infection Preventionist. The resident did not sign that consent, and the Medicare 5-Day MDS showed a BIMS score of 3, indicating severe cognitive impairment. The MDS also showed that the pneumococcal vaccination was not offered.
Failure to Maintain Required Resident Medical Records After Ownership Change
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident medical records for the required retention period, specifically for one resident whose admission MDS was submitted and accepted in early April 2022. The MDS documented that this resident had moderate cognitive impairment with a BIMS score of 11, exhibited verbal and other behavioral symptoms, and had multiple active diagnoses including hypertension, diabetes mellitus, end-stage renal disease, hyperlipidemia, seizure disorder or epilepsy, anxiety, depression, and bipolar disorder. When surveyors requested the resident’s facesheet, diagnoses list, physician orders, MAR/TAR for the full stay, progress notes, completed MDS, care plan, census list, and self-reports or investigations, the facility responded that the resident was not in the facility after March 1, 2025, and that they were unable to provide any records for this resident. Interviews with the Medical Records Director, Clinical Resource, RN Unit Manager, and DON confirmed that the facility did not have access to any paper or electronic records for this resident, or for any residents prior to March 1, 2025, unless they remained in the facility on or after that date. Staff stated that medical records were expected to be maintained for 10 years and described the contents of a complete medical record, but reported that they could not access prior records because the previous owner had stopped paying for the EMR system and no one could figure out how to access it. The facility also reported they could not provide a list of self-reports from 2022 for the same reason. Review of facility policies showed that the “Medical Record, Content of” policy required a separate medical record for each resident with specific identification data, and the “Record Retention Schedule” policy required resident medical records to be retained for 10 years and investigations for 5 years, which was not met in this case.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's medications were obtained and administered as ordered by the physician, resulting in a delay in treatment. The resident, who was admitted following a hospital stay, had a history of severe sepsis and was prescribed antibiotics cefiderocol and gentamicin upon discharge. However, these medications were not administered for eight days due to issues with obtaining them from the pharmacy. The facility's physician orders indicated that the antibiotics were to start on February 13, 2025, but the Medication Administration Record showed no doses were given until February 19, 2025. Nursing notes documented that the medications were on order and unavailable, with the provider and family being informed. Despite attempts to resolve the issue, including contacting the pharmacy and notifying the Director of Nursing (DON), the medications remained unobtained for several days. Interviews with staff and pharmacy personnel revealed communication issues and insurance authorization problems that contributed to the delay. The first pharmacy could not fill the order due to insurance constraints, and the second pharmacy was unable to provide the medications as they were outside their formulary. The DON was aware of the situation and attempted to address it, but the delay persisted, highlighting a breakdown in the facility's medication administration process.
Deficient Infection Control Practices in Wound Care
Penalty
Summary
The facility failed to ensure that their enhanced barrier precaution (EBP) policies, specifically regarding the use of personal protective equipment (PPE) during wound care, were up-to-date with professional standards of practice. During an observation of wound care for a resident with a pressure ulcer on the right hip, the Certified Wound Nurse/LPN did not wear a protective gown, only gloves, as the procedure was classified as clean. The nurse stated that according to the facility's policy, gowns were only required for wounds classified as stage III or greater, which was confirmed as the current practice by the staff. The Director of Nursing, who was also the designated Infection Preventionist, confirmed that the facility's EBP practice was based on their policy, which only required gowns for stage III or greater wounds. However, the Director of Nursing did not hold any qualifying infection prevention certification or training at the time. A review of the facility's policy revealed it was based on CDC guidance, which recommends gown and glove use for high-contact resident care activities, especially for residents with wounds or indwelling medical devices. The facility's policy had not been updated to reflect the CDC's recommendations, which were last updated in July 2022.
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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 Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montecito Post Acute Care And Rehabilitation | 1.8 mi | ★★★★★ | 1 | 0 |
| Citadel Post Acute | 2.3 mi | ★★★★★ | 0 | 0 |
| Desert Blossom Health & Rehab Center | 2.9 mi | ★★★★★ | 1 | 0 |
| Advanced Healthcare Of Mesa | 2.9 mi | ★★★★★ | 3 | 0 |
| Sante Of Mesa | 3.1 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.