Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Advanced Rehab Center Of Tustin during CMS and state inspections, most recent first.
A facility failed to document offering assistance with advance directives for three residents who were cognitively intact and able to make medical decisions, even though records showed they had not executed an advance directive and had been given information about their rights. For another resident, staff provided advance directive materials to the representative, but there was no documented follow-up on the resident’s wishes, status, or completion of the advance directive.
A resident repeatedly received insulin at the same abdominal site and was given hydralazine when SBP was below the ordered threshold. Another resident had seizure activity documented without physician notification, and also received amiodarone and midodrine outside ordered hold parameters. A third resident with a Foley and bleeding history was not routinely monitored or documented for urinary bleeding changes, and a fourth resident had repeated refusals of BG checks without a completed change-of-condition assessment.
Failure to Monitor Wandering, Alarms, Pet Safety, and Post-Fall Assessments: A resident with dementia and wandering behaviors was observed exiting bed and entering another resident’s room while the WanderGuard was documented as not functioning and later could not be located. Two other residents had repeated inconsistent documentation that bed/chair sensor alarms were not working, with no recorded corrective action. In another room, an unleashed dog was observed in the room, hallway, and on a resident’s bed while the owner was hospitalized, and a post-fall assessment for another resident was left blank after unwitnessed falls.
A resident receiving oxygen and another resident using nebulizer therapy had respiratory equipment that was not properly labeled or stored. One resident’s nebulizer mask, canister, and tubing were left out instead of being kept in a setup bag, and another resident’s portable nasal cannula was exposed to air and not stored in a bag. In addition, one resident was observed receiving oxygen at 1.5 LPM even though the MD order was for 2 LPM via nasal cannula.
Medication Storage and Labeling Deficiencies: Surveyors found an expired glucagon emergency kit stored in a med cart, oral Tylenol stored with eye drops, and internal and external meds mixed together in another cart. They also found a gabapentin bubble pack label that did not match the MD order because it was missing the hold parameter; an LVN and the DON acknowledged the findings.
Incomplete and inaccurate medical record documentation affected multiple residents. A resident lacked a completed H&P on admission, two residents had post-fall neuro checks with missing dates, overwritten or illegible time entries, and one resident had pain scores documented as zero on shifts when PRN analgesics were given for higher reported pain levels. Another resident’s POLST was incomplete and did not indicate the presence of an advance directive, even though one was in the chart.
The facility failed to fully implement its infection prevention and control program by limiting surveillance to residents prescribed antibiotics, while excluding residents with signs and symptoms of infection who were not on antimicrobials. Infection surveillance records, monthly/quarterly summaries, and floor mapping also contained inconsistent infection counts, and the IP verified the data were inaccurate. In addition, a clean personal clothing cart was left uncovered and unattended in a hallway, allowing a resident to touch the clean clothing inside while an EVS Manager and CNA were present.
Antibiotic Stewardship Documentation Not Completed: The facility failed to complete McGeer’s criteria assessments and Infection SBAR documentation for multiple residents receiving antimicrobials. Surveillance logs for several residents showed antibiotics for HAI or CAI, but many records did not state whether McGeer’s criteria was met or not met, and several medical records lacked the required infection analysis. The IP verified the missing documentation, and the DON stated the prior IP had left and a new IP had recently been hired.
The facility failed to educate and offer the COVID-19 vaccine to two LVNs and one CNA reviewed for vaccination status. Facility P&P required employee vaccination assessment, education on non-mandated vaccines, and documentation of declinations, but the IP verified there was no documentation that the staff received screening, education, or an offer of the vaccine. The CNA did not recall receiving these steps, and the DSD stated he did not provide them.
A CNA was observed standing over a resident while assisting with eating instead of being seated beside the resident. The CNA confirmed this was done and stated staff were supposed to be seated when helping residents eat. The resident had no mental capacity to make decisions, and the care plan included assistance with meals. Facility policy and the DSD both stated staff should be seated beside residents during feeding to promote dignity.
Incomplete and inaccurate psychotropic med consents were found for several residents. Surveyors reviewed orders and MARs for buspirone, Seroquel, fluoxetine, Depakote, and risperidone and found consent forms that used the wrong med category, omitted the indication and behavior manifestation, lacked required verification by two LNs, and did not identify the representative who gave telephone consent. RN 2 confirmed the documentation errors, and the DON was informed.
A resident had Vitamin A&D ointment left at the bedside without a physician order allowing self-administration. Surveyors observed the unlabeled ointment on the bedside table, and the resident said nursing staff usually gave it to him for his lips. The LVN confirmed there was no order for the ointment to be kept there or for the resident to administer it himself, and the DON stated the LPN should not have left it at the bedside.
Call Light Not Within Resident's Reach: A resident with dementia, forgetfulness, impaired mobility, and no capacity to make decisions was observed in bed yelling for help while unable to reach the call light, which was clipped at the head of the bed. An LVN confirmed the call light was out of reach and stated it should have been within the resident's reach; the care plan had already directed staff to place the call light within easy reach and encourage its use for assistance.
Delayed physician notification for urinary changes. A resident with an indwelling urinary catheter and risk for bleeding had blood noted after pulling on the catheter, but the LPN did not notify the MD when the issue was first reported and did not fully assess urine output. Later, the resident developed abdominal distension with no Foley output and was sent to the hospital. In a separate event, blood-tinged urine progressed to thick, dark blood in the catheter tubing before the MD was notified.
A resident receiving fluoxetine, mirtazapine, buspirone, and PRN lorazepam was not monitored for medication side effects, and the MAR lacked meal intake documentation. The resident’s recorded poor oral intake episodes did not match the monthly psychotropic summary for mirtazapine, and RN verified the missing monitoring and inconsistent documentation during record review.
PASARR screening was not completed or corrected for two residents. One resident was admitted under an exempted acute care hospital discharge with bipolar disorder, anxiety, and depression treatment, but no new Level I PASARR was found after the stay exceeded 30 days. Another resident had anxiety disorder and unspecified psychosis with psychotropic meds ordered, yet the hospital PASARR incorrectly stated no serious mental illness or psychotropic use, and the facility did not initiate a new Level I screen. The ADON verified the missing screenings and the DON was informed.
The facility failed to include anxiety-related medications in the care plans for two residents. One resident had an order for buspirone for anxiety, and another resident had an order for PRN hydroxyzine HCl with documented administrations, but neither care plan included a problem, goal, or interventions for the medication use or anxiety symptoms. RN and LVN interviews confirmed the omissions.
A resident with bilateral eye blindness and cataracts did not have a follow-up eye specialist appointment scheduled after an outside provider referral was documented in the chart. The resident stated she had not been able to see the eye specialist or received any information about the appointment, and the SSD said she had not received the referral information from nursing. An LVN stated she had informed SSD and nursing management via group chat about appointments for the resident.
A resident with a PICC line had incomplete IV access monitoring. Staff documented arm circumference only once despite orders to measure it, and the PICC external catheter length changed from 12 cm to 0.5 cm without documented physician notification as ordered. The RN and ADON confirmed the missing measurements and lack of documentation.
Failure to Provide Documented Nonpharmacologic Pain Interventions: Two residents received PRN Norco for pain without documented nonpharmacologic interventions first. One resident with intact cognition stated the interventions were not offered before the opioid was given, and an LVN confirmed the MAR did not show them. For another resident, the MAR showed Norco was given multiple times for pain ratings of 5 to 9 and once when pain was documented as 0/10; an RN confirmed nonpharmacologic interventions were not provided.
The facility failed to ensure safe medication administration for a resident receiving gabapentin when an LVN gave the medication without checking the resident’s RR, despite an order to hold it if RR was below 12. The facility also had an opened glucagon emergency kit in a med cart with no documentation of when it was opened or used, and it was not replaced within the required timeframe.
A facility failed to ensure the pharmacist completed the monthly drug regimen review and identified irregularities in a resident’s med regimen. A resident with Type 2 DM had orders for Humulin R sliding-scale insulin, but the MAR showed repeated refusals of insulin injections and blood sugar checks, and the pharmacy review binder contained no recommendations addressing those refusals.
A resident receiving amiodarone for arrhythmia had no documented HR checks before multiple doses were given, despite an order to hold the medication if HR was below 60 bpm. MAR review showed repeated administration without evidence that nursing staff verified the resident's HR before dosing, and an RN and the DON acknowledged the findings.
A resident with intact cognition had a physician order for baseline CBC, lipid panel, CMP, A1C, magnesium, and phosphorus testing to be completed weekly, but the medical record did not show results for the ordered labs that were due. During review, an LVN confirmed the orders were active and the record lacked the required results, and the DON stated licensed nurses were responsible for entering lab orders into the portal.
Incorrect Portion Sizes for Mechanically Altered Diet Menus: The facility failed to follow the menu for residents on IDDSI Level 4, 5, and 6 mechanically altered diets. During tray line observation, A resident’s puree, minced & moist, and soft & bite sized meals were served in smaller portions than listed on the Cook’s Spreadsheet, and the Dietary Supervisor and RD verified the scoop sizes and portions were incorrect.
IDDSI Level 5 minced and moist food was not prepared as required for four residents on a modified texture diet. The lunch tray line showed minced chicken served with thin sauce poured over the meat and kept separate from the sauce, while the cook sheet did not list gravy or sauce for the item. The RD later verified the meat should have had thickened liquid mixed into it rather than thin liquid served on top.
A resident with decision-making capacity and a hx of post-stroke status was served breakfast eggs that were too runny and not consistent with her stated preference. During an observation, she gestured that she disliked the eggs, and the Dietary Supervisor said the facility had run out of eggs. The RD later confirmed the egg shipment arrived around noon and acknowledged the resident could have been offered an alternative entree.
Unclean Kitchen Floor Drain: During a kitchen tour, surveyors observed a floor drain under a food prep sink with excessive black residue and food remnants. The Dietary Supervisor confirmed the drain was not clean, and the condition did not meet food safety and sanitation standards.
Incomplete and Inaccurate Facility Assessment: The Facility Assessment did not show input from residents or resident representatives. It also inaccurately listed a Social Services Director and only one LVN treatment nurse, even though the Social Services Assistant stated the facility had not had a Social Services Director for months and the May staff assignment showed two treatment nurses.
Two resident rooms had cold temperatures and strong breezes from the vents, with residents in one room reporting the room felt cold and using blankets for comfort. Staff confirmed the thermostat was locked behind a cover, but the key was not available in the key cabinet or with the RN when maintenance was off-site, preventing staff from adjusting the temperature.
A facility failed to keep resident records private when its public Survey Inspection Results binder in a hallway wall pocket contained two Confidential Resident Rosters. The binder was accessible for public review and included resident identifiers and names from two surveys, even though the pages were marked confidential. The Administrator confirmed the rosters should not have been placed in the public binder.
The facility failed to complete admission MDS assessments on time for two residents. One resident’s admission MDS was still incomplete, with only one of 18 sections finished, and another resident’s admission MDS was completed after the required 14-day window. Staff reviewed both records and verified the assessments were not completed within the required timeframe.
Missing Annual CNA Performance Evaluations: The facility failed to ensure that three CNA personnel files contained annual performance evaluations. During a review with the DSD, the surveyor found that the files for three CNAs listed their hire dates, but the DSD was unable to locate their most recent performance evaluations.
A resident with moderately impaired cognition alleged that a CNA physically abused them during a shower, but the incident was not immediately reported to the Administrator or external authorities as required by policy. The CNA did not report the allegation, and there was no documentation in the medical record, resulting in a delayed notification to regulatory agencies and a lack of timely investigation.
A resident with a history of healed lower extremity wounds developed a new blister and erythema, which was documented by a nurse practitioner and a CNA. Despite this, licensed nurses did not assess, document, or monitor the skin impairment, nor was a care plan initiated. The DON and staff confirmed that required assessments and documentation were not completed, resulting in a failure to provide quality care.
A resident with cognitive impairment experienced a pressure injury that progressed from Stage 1 to Stage 3, but required Braden scale risk assessments were not performed at each stage of the wound's decline. Staff interviews confirmed that assessments were only completed at admission and not when the resident's condition changed, contrary to facility policy.
Two residents who lacked decision-making capacity experienced unwitnessed falls resulting in injuries—a laceration and a skin tear. In both cases, staff failed to develop and implement care plans to address these injuries, as confirmed by medical record reviews and staff interviews, despite facility policy requiring comprehensive, measurable care plans for such changes in condition.
A resident's medical record was found to be inaccurate when a fall was not properly documented in the Fall Risk Assessment, despite other records indicating the incident. Both an RN and the DON confirmed the error, noting that the assessment should have reflected the fall as required by facility policy.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident prescribed aripiprazole for psychosis did not have documented monitoring for medication side effects, despite facility policy and care plan interventions requiring such monitoring. The resident was cognitively intact and exhibited no behavioral symptoms, and the DON confirmed the lack of documentation regarding side effect monitoring.
A resident with moderate cognitive impairment reported to an RN that a CNA made her feel uncomfortable by sitting next to her and putting his arms around her. Although the incident was internally reported to the DON, SSD, and Administrator on the same day, the required abuse report was not submitted to the state agency until several days later, contrary to facility policy.
Surveyors found multiple failures in food labeling, dating, and discarding expired items, as well as poor maintenance of kitchen equipment and improper chemical sanitization testing. Food items in refrigerators and freezers were missing labels or use-by dates, and expired foods were not discarded. Kitchen equipment, including a plate lowerator and can opener, was in disrepair, and a microwave used for resident food was unclean. Staff also failed to properly test sanitizing solution concentrations, all of which were confirmed by facility staff.
Multiple infection control deficiencies were identified, including inaccurate infection surveillance logs, improper reuse and storage of gowns by laundry staff, and storage of personal belongings with clean linen. A resident with a pending C. difficile test was not placed on contact precautions, and two residents with central lines were not on Enhanced Barrier Precautions as required. Staff were also observed failing to change gowns between residents and transferring items between residents on and off precautions, increasing the risk of disease transmission.
A resident with a Stage 3 pressure injury, who was bedbound and unable to reposition independently, did not receive proper pressure ulcer prevention care when staff failed to return the low air loss (LAL) mattress to its alternating pressure mode after care. The mattress was repeatedly left on the static setting, contrary to physician orders and facility policy, resulting in the resident not receiving the intended pressure-relieving therapy.
The facility did not ensure safe smoking practices for three residents who were allowed to keep their own smoking materials and smoke unsupervised, despite assessments indicating they required supervision. Additionally, two residents at high risk for falls were not accurately assessed or provided with appropriate fall prevention care plans, with one resident's risk being incorrectly documented and another not having a care plan developed after multiple falls. These failures were confirmed through observations, interviews, and medical record reviews.
The facility did not obtain or document baseline measurements for PICC lines and failed to label PIV sites with the required date, time, and nurse initials for four residents. These deficiencies were confirmed through observation, medical record review, and staff interviews, and were inconsistent with facility policy and physician orders.
Several residents did not receive safe and appropriate respiratory care when oxygen and nebulizer equipment was found unlabeled, undated, or improperly stored, and required signage was missing. In some cases, there were no physician's orders or care plans for oxygen use, and staff confirmed these deficiencies during interviews.
Two residents with recent hip fractures did not receive pain management in accordance with physician orders, as Norco was administered outside prescribed pain levels and care plans addressing pain and high-risk medication use were not developed. Pain monitoring was inaccurately documented, and non-pharmacological interventions were not provided or recorded prior to medication administration, as required by facility policy.
Multiple deficiencies were identified in pharmaceutical services, including mismatched controlled drug records and MARs for two residents receiving hydrocodone-acetaminophen, lack of pain assessments, failure to rotate insulin injection sites for a resident with diabetes, a nurse not instructing a resident to chew aspirin as required, missing documentation for famotidine administration, and insulin glargine being held without proper physician orders or documentation. These issues were confirmed through observations, record reviews, and staff interviews.
Surveyors found that a resident's hydrocodone-acetaminophen was left in an IV cart after discharge, several ointments lacked expiration or received dates, medication disposal bins were left unlocked with insulin pens inside, and a supplement bottle was observed with sticky residue. Nursing staff and the DON confirmed these lapses in medication storage, labeling, and cleanliness.
Advance Directive Assistance and Follow-Up Not Documented
Penalty
Summary
The facility failed to ensure assistance in the formulation of an advance directive was offered for Residents 10, 89, and 118. Facility policy stated that if a resident or resident representative had not established advance directives, staff would offer assistance in establishing them and document the offer and the resident’s decision. Resident 10 was admitted with the ability to make medical decisions and was cognitively intact; Resident 89 had the capacity to understand and make medical decisions; and Resident 118 also had the capacity to understand and make medical decisions. For each of these residents, the Advance Directive Acknowledgement showed they had not executed an advance directive and had been provided information on the right to formulate one, but the records did not show that assistance was offered or whether the residents accepted or declined assistance. The facility also failed to follow up on advance directive status for Resident 93. Resident 93’s POLST showed no advance directive, and the Social Services assessment documented that reading materials were provided, but there was no evidence of follow-up with the resident’s representative regarding completion or status of an advance directive. The record did not show documented discussions of the resident’s wishes or follow-up attempts to determine whether the resident had an existing advance directive, wished to complete one, or declined to formulate one. The Social Services Assistant stated the resident was confused and that advance directive information was discussed with the resident’s representative, but documentation of follow-up regarding status or completion was not available.
Failure to Follow Orders, Monitor Changes, and Document Resident Conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and care plans for four sampled residents. The report identified failures involving monitoring for bleeding and urinary changes, insulin injection site rotation, administration of medications outside ordered parameters, completion of change-of-condition assessments, and notification of the physician for seizure activity. These findings were based on observation, interview, and medical record review. For one resident with intact cognition, the record showed an order for insulin lispro to be given before meals and at bedtime with instruction to rotate injection sites. The location administration record showed the insulin was repeatedly given in the LLQ of the abdomen on multiple consecutive administrations. The same resident also had an order for hydralazine 25 mg every six hours as needed for hypertension if SBP was greater than 160 mmHg, but the MAR showed the medication was administered when SBP readings were below 160 mmHg. Staff interviews confirmed the injection sites were not rotated and that hydralazine should not have been given under those blood pressure readings. For another resident, the record showed orders to monitor for seizure activity every shift and notify the physician if noted, and to administer lorazepam as needed for seizures. The MAR documented seizure activity on two shifts and lorazepam administration on two occasions, but the record did not show physician notification or assessment before, during, and after the seizure activity. The same resident also had orders for amiodarone to be held if heart rate was less than 60 beats per minute, yet it was administered when the pulse was 57, and midodrine to be held if SBP was greater than 130 mmHg, yet it was administered when SBP readings were 132/70 and 131/77. Staff interviews verified these administrations were outside the ordered parameters. For a third resident with an indwelling urinary catheter and a history of bowel and bladder alteration, the care plan included monitoring and reporting signs of UTI and bleeding, including blood in the urine and other urinary changes. The record showed episodes of blood noted with catheter pulling and later blood-tinged urine progressing to thick, dark, bright blood in the catheter tubing, but the record did not show routine monitoring and documentation of bleeding and urinary changes per the care plan, and one episode lacked documentation of when the bleeding was first identified. For another resident receiving insulin, the record showed multiple refusals of blood sugar checks, but the change-of-condition assessment was not consistently completed despite repeated refusals. Staff acknowledged that repeated refusals should have triggered a current change-of-condition assessment and physician notification.
Failure to Monitor Wandering, Alarms, Pet Safety, and Post-Fall Assessments
Penalty
Summary
The facility failed to ensure Resident 93 remained protected from accident hazards related to wandering and elopement risk management. Resident 93 had diagnoses including dementia, Alzheimer’s disease, and sundowning syndrome, and the record showed observed wandering and exit-seeking behaviors. Although the care plan identified the resident as an elopement risk and wanderer related to attempting to leave the facility unattended, the elopement risk assessment scored the resident below the threshold for high risk and stated the resident had no history of elopement, wandering, or getting lost. Physician’s orders required monitoring for wandering, checking WanderGuard function daily, and checking WanderGuard placement every shift, but the record showed the WanderGuard was documented as not functioning on multiple occasions and there was no documentation of corrective action. Surveyors also observed the resident getting out of bed, with the incontinent brief pulled down, entering another resident’s room, and later getting out of bed again before being assisted back to bed. The resident was also observed without a WanderGuard, and staff could not locate the device. The facility also failed to consistently monitor bed and chair sensor alarms for Resident 8 and Resident 19 as ordered. Resident 8 had physician’s orders for bed and wheelchair sensor alarms and for the alarms to be checked every shift, and Resident 19 had similar orders for sensor alarm function checks every shift and for bed and wheelchair sensor alarms to alert staff when the resident tried to get up unassisted. For both residents, the MARs showed repeated documentation that the alarms were not working or were inconsistently documented across shifts. The records did not show interventions or corrective actions when the alarms were documented as not functioning. Surveyors observed Resident 8 trying to get out of bed while the bed alarm was sounding, and Resident 19 was observed asleep in bed with a bed alarm device at bedside. The facility failed to monitor an unleashed dog inside the building while the animal’s owner was hospitalized and the dog was being cared for by Resident 118. The dog was observed walking unleashed in Resident 118’s room, in the hallway outside the room, and later sitting on the resident’s bed. Resident 118 was cognitively intact, used a manual wheelchair, and was receiving oxygen via nasal cannula. The care plan acknowledged that the resident shared a room with a roommate who had an approved pet dog and stated the dog should be supervised and facility policy followed, but it did not address who was responsible for caring for the dog, whether the dog should be leashed, or whether Resident 118 could safely manage and control the animal at all times. The record did not show documentation of the resident’s ability to care for or control the pet. The facility also failed to complete post-fall Fall Risk Assessments for Resident 143. The resident had unwitnessed falls and was found lying on the floor next to the bed and later on the floor after another unwitnessed fall. The Fall Risk Assessment forms dated 4/9/26 and 4/20/26 were reviewed and both were blank, with all sections incomplete. The DON reviewed the forms and verified that both assessments were incomplete.
Respiratory Equipment Not Properly Stored or Labeled; Oxygen Not Given as Ordered
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents reviewed for respiratory services. Resident 118 was observed lying in bed receiving oxygen at 2 LPM via nasal cannula, and a nebulizer mask with canister and tubing was seen on top of the bedside drawer rather than stored in a setup bag. The nebulizer equipment was not labeled, and the plastic setup bag hanging on the bedside drawer was dated 4/13/26. The RN Consultant verified that the nebulizer equipment was not labeled or stored in the setup bag, and the DON stated the equipment should have been dated and changed weekly. Resident 118 had a physician’s order for ipratropium-albuterol solution via inhalation every six hours for shortness of breath. Resident 83 was observed in bed receiving oxygen at 1.5 LPM via nasal cannula, while the resident stated she was supposedly receiving oxygen at 2 LPM. A portable oxygen tank with an unlabeled nasal cannula was observed on a wheelchair exposed to air and not stored in a bag, and no bag was present on the wheelchair. Resident 83 stated she used the oxygen when she got up in the wheelchair during the day and did not know when the nasal cannula on the wheelchair was last changed. The resident had a physician’s order for continuous oxygen at 2 LPM via nasal cannula, and RN 1 verified that order. The DSD and DON both verified that the nasal cannula was not labeled and stored in a bag when not in use, and the DON stated licensed nurses are expected to change and label nasal cannulas weekly and administer oxygen as ordered by the physician.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage in Medication Cart A and Medication Cart B. During inspection of Medication Cart A, surveyors observed an opened glucagon emergency kit with an expiration date of 2/2026 stored in the cart, and LVN 4 verified it was expired and should not have been there. In the same cart, a bottle of Tylenol and a Tear Plus eye drop medication were stored together in the top drawer, and LVN 4 confirmed that the oral medication and eye drops should not have been stored together. The facility’s Medication Storage policy stated that medications are to be stored safely and that orally administered medications are kept separate from externally used medications, and that outdated medications are to be removed from stock and disposed of according to procedure. The facility also failed to ensure the gabapentin bubble pack label matched the physician’s order for a resident who was readmitted to the facility. The order summary showed gabapentin 100 mg, two capsules by mouth twice a day, with a hold parameter for respiratory rate less than 12 breaths per minute, but the bubble pack label did not include that hold parameter and no change-of-direction sticker had been applied. In Medication Cart B, surveyors observed internally used medications stored in the same compartment as multiple external or inhaled/nasal products, including saline nasal spray, Dulera inhalation aerosol, oxymetazoline nasal spray, ipratropium bromide-albuterol sulfate, and fluticasone-salmeterol, and LVN 6 verified the observation.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four sampled residents. For Resident 92, the medical record did not show that an H&P examination was completed upon admission. During interview and concurrent record review, the RN and MRD verified the H&P was missing and stated it should have been completed. For Resident 143, the MAR showed PRN acetaminophen and hydrocodone-acetaminophen were administered for documented pain levels ranging from 2 to 8, but the shift pain monitoring entries recorded the resident's pain as zero for those same shifts. The LVN reviewing the record stated the highest pain level should be documented for each shift, while the DON stated the licensed nurse should document the resident's highest level of pain for the shift, not the pain level after medication was given. Resident 143's post-fall neurological assessment flow sheets also contained overwritten time entries that were illegible, and one assessment time was documented at 0340 instead of the scheduled 0040. For Resident 7, the post-fall neurological assessment flow sheet dated 2/25 showed overwritten time entries that were difficult to read, 19 of 20 date entries were left blank, and the final assessment due on 2/27/26 at 0015 hours was recorded at 0815 hours with a blank date. For Resident 32, the H&P showed the resident had capacity to understand and make decisions, and the record contained an advance health care directive, but the POLST did not indicate whether the resident had an advance directive. The ADON and DON acknowledged the POLST was incomplete and that the advance directive was present in the medical record.
Infection Surveillance and Clean Linen Cart Deficiencies
Penalty
Summary
The facility failed to establish, maintain, and implement its Infection Prevention and Control Program according to accepted standards of practice. The facility’s surveillance process was not comprehensive because infection surveillance from November 2025 through April 2026 was conducted only for residents who had signs and symptoms of infection and were prescribed antibiotics. The Infection Preventionist stated that residents with signs and symptoms of infection who were not prescribed antibiotics were not included in the Infection Surveillance list, and that these residents were only monitored in progress notes. When asked whether prior symptoms would be remembered if symptoms recurred, the Infection Preventionist stated she would not know. Facility records also showed inconsistent and inaccurate infection surveillance documentation. The Infection Prevention and Control Surveillance Log, the Infection Control Monthly/Quarterly Summary Reports, and the infection floor mapping for November 2025 through February 2026 did not match each other. For example, the surveillance log listed different HAI and CAI totals than the monthly/quarterly summary reports for the same months, and the floor mapping showed different total infection counts. During interview and document review, the Infection Preventionist verified that the data in these records were inaccurate and stated the previous Infection Preventionist was no longer employed at the facility. The DON was informed of these findings and acknowledged them. The facility also failed to keep a clean personal clothing cart covered and secured when unattended. A review of the Laundry and Linen policy stated clean linen should remain hygienically clean through measures such as covering clean linen carts. During observation, the cart cover was left open and unattended in a resident hallway while the EVS Manager delivered clothing to a resident’s room. A resident approached the open cart and touched the clean clothing inside while a CNA observed the resident. The CNA confirmed the resident touched the clean clothing and stated the resident was looking for a blouse. The EVS Manager verified that resident clean clothing was transported on a covered cart and that the cart should remain closed when left unattended.
Antibiotic Stewardship Documentation Not Completed
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not completing an assessment for McGeer’s criteria to determine whether infections were true infections for two final sampled residents and fourteen nonsampled residents. The facility’s policy stated that the IP would collect and analyze infection surveillance data, coordinate data collection, monitor adherence to infection control policies and procedures, and use McGeer/Loeb and Stone criteria to guide antibiotic initiation and documentation. However, the monthly Infection Prevention and Control Surveillance Logs from November 2025 through April 2026 did not consistently show whether infections met or did not meet McGeer’s criteria, and the Infection Screening Evaluation in the medical records did not show all criteria used to assess for McGeer’s criteria. For Resident 90, who had no capacity to understand and make decisions, the surveillance log showed ciprofloxacin eye drops for an HAI and indicated McGeer’s criteria was met, but the medical record did not contain an Infection SBAR showing infection analysis. For Resident 40, who had capacity to understand and make decisions, the log showed nystatin powder for a CAI and indicated McGeer’s criteria was met, but the Infection SBAR was not completed. For Resident 44, who was able to make needs known but had no capacity to make decisions, the log showed acyclovir tablets for an HAI and later erythromycin changed to azithromycin for another HAI, and the medical record did not show an Infection SBAR for either episode. Resident 59 had no capacity to make decisions, was prescribed cefepime IV changed to doxycycline, and the log did not indicate whether McGeer’s criteria was met or not met; the Infection SBAR was also absent. Additional records showed the same pattern for multiple other residents. Resident 27 had an Infection SBAR that stated the infection analysis did not meet McGeer’s criteria, but the surveillance log for ceftriaxone IV did not indicate whether McGeer’s criteria was met or not met. Resident 158’s December 2025 log entries for ceftriaxone IV, ertapenem IV, and doxycycline did not identify CAI or HAI and did not state whether McGeer’s criteria was met or not met, and the Infection SBAR was incomplete with signs and symptoms not indicated. Resident 159’s log for metronidazole did not indicate whether McGeer’s criteria was met or not met, and the Infection SBAR was absent. Resident 148’s log for nitrofurantoin tablets did not indicate whether McGeer’s criteria was met or not met, and the Infection SBAR was absent. Similar omissions were found for Residents 85, 161, 11, 163, 164, 165, 88, and 8, whose logs either did not indicate whether McGeer’s criteria was met or not met or whose medical records did not contain the Infection SBAR documenting the infection analysis. The DON stated the previous IP had left the facility and a new IP had recently been employed.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure that three of three staff members reviewed for COVID-19 vaccination status, including two LVNs and one CNA, were educated and offered the COVID-19 vaccine. The report states the facility did not provide the educational materials describing the risks and benefits of the COVID-19 vaccines and did not offer the vaccine to these employees. Review of the facility's P&P titled Employee Infection and Vaccination Status showed employees are to be assessed for vaccination status prior to or upon duty assignment, provided educational materials for non-mandated vaccinations, and documented if vaccinations are declined. During interview and document review, the IP verified there was no documentation showing employee screening, education, or offering of the COVID-19 vaccine for the three staff members. The CNA stated she did not remember receiving screening, education, or an offer of the vaccine, and the DSD stated he did not provide the screening, education, or offer the vaccine to employees.
Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure resident care was provided in a manner that maintained and enhanced dignity for Resident 19. During observation on 5/5/26 at 0800 and 0805 hours, CNA 2 was seen standing over Resident 19 while assisting the resident with eating, with the resident seated upright in bed. During a concurrent interview at 0810 hours, CNA 2 confirmed she had been standing while assisting with the meal and stated she was supposed to be seated when helping a resident eat. Facility policy titled "Assisting the Impaired Resident with In-Room Meals" stated that if staff are going to be seated during feeding, a chair should be positioned where it is convenient for both the staff member and the resident. Resident 19 had been readmitted to the facility and had an H&P dated 8/7/25 showing no mental capacity to make decisions. The care plan included a problem dated 7/6/23 for alteration in physical functioning with interventions to assist with meals. The DSD stated staff should be seated beside residents when assisting with eating to promote dignity, and the DON was informed and acknowledged the findings.
Incomplete and inaccurate informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure informed consent documentation for psychotropic medications was accurate and complete for multiple residents. Review of facility policy showed that informed consent for psychotherapeutic medications was to be verified by a licensed nurse and that material information about the medication was to be disclosed. Surveyors reviewed records for Residents 8, 19, 93, and 148 and found deficiencies in the consent forms related to medication category, indication for use, behavior manifestations, verification signatures, and telephone consent documentation. For Resident 93, physician orders included buspirone for anxiety and Seroquel for psychosis. The informed consent form used for buspirone was labeled for an antidepressant and contained side effects for antidepressants rather than antianxiety medications. The consent form used for Seroquel 25 mg was labeled for anticonvulsant/antimanic medication rather than antipsychotic medication, and the consent form used for Seroquel 50 mg was labeled for antianxiety medication rather than antipsychotic medication. During interview and record review, RN 2 verified that the consent forms were inaccurate for the medications being administered. For Resident 148, the record showed orders for fluoxetine and buspirone. The informed consent for fluoxetine showed only one licensed nurse verified the consent via phone, and the informed consent for buspirone did not include the reason for use or the behavior manifestation related to the medication. For Resident 19, the consent forms for Depakote and risperidone did not include the administration method or whether the medications had a caution and warning summary, FDA-approved use, and black box warning label; the risperidone consent also did not identify the resident’s representative who gave telephone consent. For Resident 8, the Seroquel consent form did not identify the resident’s representative who gave telephone consent. RN 2 confirmed these documentation omissions during the interviews, and the DON was informed of the findings.
Bedside Medication Left Without Order
Penalty
Summary
The facility failed to ensure medications were safely administered for one resident who had Vitamin A and D ointment at the bedside without a physician’s order to keep the medication there. During an initial tour, surveyors observed an unlabeled ointment in a medication cup on top of the resident’s bedside table, and the resident identified it as Vitamin A&D ointment that nursing staff usually gave him to apply on his lips. Review of the resident’s order summary did not show an order for self-administration of the ointment. The resident’s record showed a physician progress note stating the resident had no capacity to make decisions, while the MDS assessment showed a BIMS score of 14, indicating intact cognition. A concurrent interview with an LVN confirmed the ointment was on the bedside table and that there was no physician’s order for the ointment or for the resident to administer it himself. The DON stated the licensed nurse should not have left the Vitamin A&D ointment on the resident’s bedside table.
Call Light Not Within Resident's Reach
Penalty
Summary
The facility failed to provide a reasonable accommodation for Resident 136 by not ensuring the call light was within reach. On 5/5/26 at 0734 hours, the resident was observed lying in bed and yelling for help. When asked if she could call staff, the resident said yes and began searching for the call light button, which was clipped at the head of the bed and could not be reached. At 0736 hours, an LVN was called into the room and verified that the call light was not within the resident's reach. During the observation, the LVN moved the call light button closer to the resident and repositioned her in bed, stating that the resident was forgetful but able to use the call light to request assistance and that it should have been within reach. The resident was later observed using the call light to ask staff for a drink. Record review showed the resident had been admitted to the facility, had no capacity to understand and make decisions per the H&P, and had dementia, forgetfulness, impaired mobility, and required staff assistance with ADLs. The care plan included placing the call light within easy reach and encouraging the resident to use it for assistance.
Delayed Physician Notification for Urinary Changes
Penalty
Summary
The facility failed to timely notify the resident’s physician of changes in condition for one of one sampled residents reviewed for change of condition. Resident 4 had an indwelling urinary catheter and care plan interventions to monitor and report signs and symptoms of a UTI, as well as to monitor, document, and report blood-tinged or red urine due to aspirin use. On 2/10/26, a CNA reported that Resident 4 was pulling on the catheter and blood was observed. An LVN assessed the resident, flushed the catheter with about 30 ml of irrigation fluid, and documented that no bleeding was noted and the catheter was patent and draining. The LVN did not check the drainage bag for blood or urine output and did not notify the physician at that time because no abnormal findings were observed. Later that same day, the resident’s abdomen was noted to be visibly distended and firm, and there had been no urine output in the Foley catheter since 0700 hours. The physician was then notified and the resident was transferred to the acute care hospital. In a separate event on 2/17/26, Resident 4 was noted earlier in the evening to have blood-tinged urine, and at about 0200 hours thick, dark, bright blood was seen throughout the catheter tubing. The nurse left to change the tubing and planned to monitor the bleeding, but when returning found the resident unresponsive with abnormal vital signs; the physician was notified and 911 was called at about 0240 hours. The record did not show when the initial blood-tinged urine was first observed, and the ADON verified the physician should have been notified immediately when bleeding was first observed.
Failure to Monitor Psychotropic Medication Side Effects and Match Intake Documentation
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary psychotropic medication use because the resident was not monitored for side effects related to lorazepam, buspirone, fluoxetine, and mirtazapine. The resident had physician orders for fluoxetine for depression, mirtazapine for depression manifested by poor oral intake, buspirone for anxiety, and lorazepam as needed for anxiety. Review of the MARs and medical record showed the resident received these medications during April and May 2026, but side effect monitoring was not documented for the use of these medications, and the resident’s meal intake was not documented on the MAR. The record also showed the resident’s documentation for oral intake did not match the monthly psychotropic summary for mirtazapine. The Documentation Survey Report showed multiple episodes when the resident ate 26% to 50% or 0% to 25% of meals, while the Monthly Psychotropic Summary Sheet for Remeron reflected only four episodes of poor oral intake less than 50% each meal. During interview and concurrent record review, RN 2 verified there was no side effect monitoring for lorazepam, buspirone, fluoxetine, and mirtazapine, and verified the monthly behavior summary for mirtazapine did not match the RNA documentation of episodes when the resident ate less than 50%. The DON was informed and acknowledged the findings.
PASARR Screening Not Completed or Corrected for Two Residents
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately and timely for two sampled residents. The facility’s policy stated that all new admissions and readmissions are screened for mental disorder, intellectual disabilities, or related disorder under Medicaid PASARR, and that a Level I screen is completed for all potential admissions. Resident 10 was admitted with diagnoses including bipolar disorder and anxiety disorder, and the record showed a physician order for duloxetine for depression. A PASARR Level I screening dated 3/31/26 identified a serious mental illness and exempted acute care hospital discharge status, and the DHCS notice stated that if the resident remained in the nursing facility for more than 30 days, a new Level I screening was required on the 31st day. The medical record did not show that a new PASARR Level I screening was completed after Resident 10 stayed beyond 30 days. Resident 32 was admitted with diagnoses of anxiety disorder and unspecified psychosis. The physician order summary included buspirone for anxiety and later Seroquel for psychosis as manifested by delusional ideation. The PASARR Level I screening completed by the acute care hospital stated the resident had no diagnosed serious mental illness and was not receiving psychotropic medications. The medical record did not show that the facility initiated a new PASARR Level I screening to correct the inaccurate hospital-completed screening. During interview and record review, the ADON verified that Resident 10 was admitted under exempted acute care hospital discharge status, that a new Level I screening was required when the stay exceeded 30 days, and that she could not find documentation of a new screening for either resident. The DON was informed and acknowledged the findings.
Care Plans Did Not Address Anxiety Medications
Penalty
Summary
The facility failed to develop a comprehensive, person-centered plan of care that reflected the individual care needs of two sampled residents. For one resident, the medical record showed a physician’s order for buspirone 5 mg by mouth every 12 hours for anxiety manifested by verbalization of feeling anxious, but the care plan did not include a problem, goal, or interventions addressing the medication use. During interview and record review, RN 2 verified the resident was receiving buspirone as ordered and confirmed no care plan had been developed for it. For another resident, the MAR showed a physician’s order for hydroxyzine HCl 25 mg by mouth every eight hours as needed for anxiety, with multiple documented administrations, and the order remained active on the order summary report. However, the care plan did not include any problem, goal, or interventions addressing the resident’s use of hydroxyzine HCl or anxiety symptoms. During interview and concurrent record review, LVN 9 verified the resident was receiving hydroxyzine HCl for anxiety and stated the care plan should have included it.
Failure to Schedule Follow-Up Eye Specialist Appointment
Penalty
Summary
The facility failed to provide necessary treatment and follow-up care to maintain the vision needs of Resident 123, who was readmitted to the facility and had diagnoses including bilateral eye blindness. A medical record review showed an eye specialist progress note dated 1/21/26 documenting diabetes and bilateral eye cataracts, and the note indicated the resident was referred for follow-up with another eye specialist. During an interview on 5/5/26, Resident 123 stated she had not been able to see her eye specialist and had not received any information regarding a follow-up appointment. On 5/6/26, the Social Services Assistant stated she had not received any information about the referral and explained that nursing staff were responsible for informing Social Services of any follow-up appointments recommended by outside providers. The Social Services Assistant verified the 1/21/26 progress note showed a referral to another eye specialist and stated she would begin follow-up. Also on 5/6/26, LVN 6 stated she informed the SSD and nursing management via a group chat about any appointments for Resident 123.
PICC Line Monitoring and Documentation Failure
Penalty
Summary
The facility failed to properly maintain and assess the IV access for one resident with a single-lumen PICC line in the right upper arm. The resident was observed in bed with a PICC dressing dated 5/4/26. The facility’s PICC dressing change policy stated that transparent dressings are changed at least weekly and that the external catheter length is obtained upon admission, during dressing changes, or if signs or symptoms of complications are present. The resident had physician orders dated 4/2/26 and 4/28/26 to document arm circumference one time only and to measure the PICC external catheter length with each dressing change and as needed, with notification to the physician if the external length changed. The record showed arm circumference was documented once at 24 cm on 4/3/26 with no further measurements. PICC dressing changes occurred multiple times in April and May 2026, and the external catheter was documented as 12 cm on several dates but as 0.5 cm on 4/29/26 and 5/6/26. RN 2 and the ADON confirmed the arm circumference was not measured with each dressing change and that there was no documented evidence the physician was notified when the external catheter length changed from 12 cm to 0.5 cm.
Failure to Provide Documented Nonpharmacologic Pain Interventions
Penalty
Summary
The facility failed to ensure appropriate pain management for two residents who were receiving PRN opioid pain medication. The facility’s pain management policy stated that nonpharmacological interventions may be used alone or with medications and listed interventions such as relaxation, adjusting room temperature or lighting, repositioning, toileting, music/TV, snacks, and warm or cold compresses. The policy also stated that results of interventions are to be documented and communicated to the provider when appropriate. For one resident, the medical record showed an order for hydrocodone-acetaminophen (Norco) 10-325 mg every eight hours as needed for moderate to severe pain, with documentation of nonpharmacological interventions required. The MAR showed multiple administrations of the medication for reported pain levels ranging from 6 to 9. During interview, the resident stated the medication was received for pain management but nonpharmacological interventions were not offered before the medication was given. The LVN reviewing the record confirmed the MAR did not show that nonpharmacologic interventions were provided prior to administration. For the second resident, the medical record showed an order for Norco 5/325 mg every six hours as needed for moderate to severe pain, with nonpharmacological interventions to be documented. The MAR showed multiple doses given for pain levels from 5 to 9, and one dose given when the documented pain level was 0/10. Review of the record did not show evidence that nonpharmacological interventions were provided before Norco was administered. An RN confirmed that nonpharmacologic interventions were not provided when the resident complained of pain and that Norco was administered when the pain level was 0/10.
Medication Administration and Emergency Kit Handling Deficiencies
Penalty
Summary
The facility failed to ensure safe and appropriate medication administration for Resident 99 when LVN 4 administered gabapentin 100 mg, two capsules by mouth twice daily, without checking the resident’s respiratory rate. The physician’s order required the medication to be held if the respiratory rate was less than 12 breaths per minute. During the medication administration observation, LVN 4 prepared and gave the gabapentin without obtaining the respiratory rate, and later stated that charge nurses were responsible for checking vital signs and that she did not check the resident’s respiratory rate before giving the medication. The facility also failed to document when a glucagon emergency kit in Medication Cart A was opened and failed to replace it within 72 hours as required by facility policy. During inspection of the cart, the glucagon emergency kit was found opened and unsealed, with no documentation showing when it had been opened or for which resident it had been used. LVN 4 could not locate any log documenting the kit’s use and stated the kit should have been immediately replaced after opening, with pharmacy notified for replacement.
Pharmacy Review Did Not Address Repeated Insulin and Blood Sugar Check Refusals
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review and identified and reported irregularities in Resident 123’s medication regimen, including review of the medical chart, in accordance with the facility’s policies and procedures. Resident 123 was readmitted to the facility with a diagnosis of Type 2 Diabetes Mellitus and had a physician’s order for Humulin R insulin injections per sliding scale. Review of the April and May 2026 MARs showed multiple episodes in which the resident refused insulin injections and blood sugar checks. However, the facility’s Pharmacy Recommendations Binder for 2026 contained no documented pharmacy recommendations addressing the resident’s ongoing refusals of insulin injections and blood sugar monitoring. During a telephone interview, the pharmacy consultant was informed of and verified these findings.
Failure to Monitor Heart Rate Before Amiodarone Administration
Penalty
Summary
The facility failed to ensure one sampled resident, Resident 148, was free from unnecessary medications when the resident's heart rate was not documented before amiodarone was administered as ordered. The physician's order, dated 3/23/26, directed staff to give amiodarone 200 mg by mouth twice daily for arrhythmia and to hold the medication if the heart rate was less than 60 beats per minute. Review of the MAR for April and May 2026 showed the resident received amiodarone from 4/1/26 through 4/26/26 at 0900 and 1700, and again from 4/29/26 through 5/5/26 at 0900 and 1700. However, there was no documented evidence that licensed nurses checked the resident's heart rate before administering the medication from 4/1/26 through 4/22/26 at both scheduled times, or on 4/23/26 at 0900. RN 2 verified these findings during interview and concurrent record review, and the DON was informed and acknowledged the findings.
Ordered Laboratory Tests Not Completed
Penalty
Summary
The facility failed to ensure that laboratory testing ordered by the physician was completed for Resident 83. Resident 83 was admitted and later readmitted to the facility, and an MDS assessment showed a BIMS score of 14, indicating intact cognition. A physician order dated 4/25/26 directed baseline laboratory testing, including CBC, lipid panel, CMP, glycohemoglobin A1C, magnesium, and phosphorus, to be completed on Monday and then weekly thereafter. Review of the medical record did not show results for the ordered laboratory tests that were due on 4/27/26 and 5/4/26. During a concurrent interview and record review, LVN 4 verified that the laboratory orders were active and required weekly testing beginning 4/27/26, and confirmed the record did not contain the required results. The DON later stated that licensed nurses were responsible for entering laboratory orders into the laboratory portal to ensure completion.
Incorrect Portion Sizes for Mechanically Altered Diet Menus
Penalty
Summary
The facility failed to follow the menu for residents receiving mechanically altered diets, affecting 25 of 91 residents. Review of the Diet Tally dated 5/6/26 showed three residents had physician orders for an IDDSI Level 4 (Puree) diet, four residents had orders for an IDDSI Level 5 (Minced & Moist) diet, and 18 residents had orders for an IDDSI Level 6 (Soft & Bite Sized) diet. The facility’s Cooks Spreadsheet for the lunch meal specified that the IDDSI Level 4, 5, and 6 diets should each receive 3/4 cup of sweet and sour chicken and 1/2 cup of sesame noodles, with the food prepared according to the diet level. During observation of the lunch meal tray line at 1152 hours, the IDDSI Level 4, 5, and 6 meals were each served 1/3 cup of sweet and sour chicken and 1/3 cup of the accompanying side item instead of the portions listed on the spreadsheet. Photographs were taken of the tray line portion sizes. During interview on 5/7/26 at 0930 hours, the Dietary Supervisor and RD reviewed the photographs and verified that the scoop sizes for the IDDSI Level 4 sweet and sour chicken and stir fry vegetables, the IDDSI Level 5 sweet and sour chicken and sesame noodles, and the IDDSI Level 6 sweet and sour chicken and sesame noodles were incorrect, and that the portions served did not meet the amounts listed on the Cook’s Spreadsheet.
IDDSI Level 5 Diet Not Prepared to Required Consistency
Penalty
Summary
Food for residents on textured-modified diets was not prepared in accordance with accepted standards for four of 91 residents receiving IDDSI Level 5 diets. The facility’s Diet Tally dated 5/6/26 showed four residents were on a Level 5 Minced and Moist diet, and the Cooks Spreadsheet for the lunch meal listed 3/4 cup minced and moist chicken for that diet but did not include a sauce or gravy. During a 5/6/26 lunch tray line observation, the Level 5 minced and moist chicken was served with a thin sauce poured over the meat, and the minced/moist chicken was kept in a separate steam table pan from the sauce. The IDDSI Framework 2.0 dated July 2019 states Level 5 Minced and Moist should be soft and moist with no separate thin liquid, and meat should be finely minced and served in thick smooth sauce or gravy with excess liquid drained. On 5/7/26, the RD reviewed the photograph of the served meal and verified the Level 5 meat should have thickened liquid mixed into the meat rather than thin liquid served on top of it.
Food Preference Not Honored for Breakfast Eggs
Penalty
Summary
The facility failed to ensure that Resident 107’s food preference was honored when her breakfast eggs were served too runny and not consistent with her stated preference. During an observation and concurrent interview on 5/5/26 at 8:15 a.m., Resident 107 was seen with a breakfast tray that included sunny side-up eggs that appeared runnier than typically served. She gestured to the Dietary Supervisor to show that she disliked the runny eggs, and the Dietary Supervisor told her the facility had run out of eggs. Medical record review showed Resident 107 was admitted to the facility and had the capacity to make decisions. Her H&P dated 3/21/26 listed post-stroke status among her diagnoses. On 5/7/26 at 8:28 a.m., Resident 107 indicated she ate the eggs served on 5/5/26 but did not like extra runny eggs. On 5/8/26 at 9:45 a.m., the RD confirmed the facility had run out of eggs on 5/5/26 and stated the egg shipment arrived around noon that day. The RD acknowledged Resident 107 could have been offered an alternative entree rather than being served eggs that were not consistent with her food preference.
Unclean Kitchen Floor Drain
Penalty
Summary
The facility failed to ensure food safety and sanitation guidelines were followed when a floor drain in the kitchen was found unclean. During the initial tour of the kitchen, an observation and concurrent interview with the Dietary Supervisor identified a floor drain located under a food preparation sink with excessive black residue and food remnants. The Dietary Supervisor verified that the floor drain was not clean. The deficiency was cited because the nonfood contact surfaces of equipment are required to be kept free of dust, dirt, food residue, and other debris.
Incomplete and Inaccurate Facility Assessment
Penalty
Summary
The facility failed to ensure the Facility Assessment was complete and accurate. Review of the Facility Assessment dated [DATE] showed no evidence that input from residents or resident representatives was obtained to complete the assessment. The assessment also stated that the facility employed a Social Services Director and one LVN treatment nurse. During an interview on 5/6/26 at 0946 hours, the Social Services Assistant stated the facility had not had a Social Services Director since March or April 2026. Review of the facility's May 2026 monthly staff assignment showed that two treatment nurses were employed by the facility. On 5/7/26 at 1400 hours, the Administrator was informed and verified these findings.
Uncomfortable Room Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for two resident rooms, Rooms A and B, when the room temperature was not maintained at a comfortable level. During the initial tour on 5/5/26 at 0815 hours, two residents were observed inside Room A with blankets covering their bodies, and both stated that the temperature in the room was cold after 1730 hours. The temperature inside Room A was also felt to be cold during the observation. On 5/6/26 at 0750 hours, a cold breeze was again felt inside Room A. At the same time, Room B was observed with a cool strong breeze coming out of the vent and moving a privacy curtain near the vent. During an interview on 5/6/26 at 0843 hours, the Maintenance Assistant verified that a cool breeze was coming out of the vents inside Rooms A and B. The Maintenance Assistant stated staff could retrieve the key from the key cabinet or ask the supervising nurse for the key to open the covered, locked thermostat and adjust the temperature when maintenance was not in the facility. The Maintenance Director was observed checking the key cabinet and not finding the thermostat key, and RN 2 stated she did not have the key and checked a drawer full of keys. The Maintenance Director acknowledged the key to open the covered locked thermostat was not available to staff during the hours maintenance staff were not in the facility.
Confidential Resident Rosters Left in Public Survey Binder
Penalty
Summary
The facility failed to protect residents' identifiable information when its Survey Inspection Results binder, intended for public viewing, contained two Confidential Resident Rosters. On 5/7/26 at 1100 hours, the binder was observed in a wall pocket in the hallway between the front lobby and Nurse's Station A and was accessible for public review. The binder included a roster from an Abbreviated Survey dated 2/19 - 2/24/26 listing five resident identifiers with their names, and another roster from an Abbreviated Survey dated 4/15/26 listing four resident identifiers with their names. Both rosters were marked confidential and had the word "Confidential" printed diagonally across the page in large grey font. During an interview and concurrent document review at 1128 hours, the Administrator verified that the confidential resident rosters should not have been placed in the public survey binder for public view.
Late and Incomplete Admission MDS Assessments
Penalty
Summary
The facility failed to timely complete admission MDS assessments for two of 20 sampled residents. For Resident 92, the admission MDS assessment was dated but remained incomplete, with only one of 18 sections completed, and it was not finished within the required 14-day timeframe after admission. During an interview and concurrent medical record review, the MDS Coordinator reviewed the record and verified that the assessment was still incomplete and late. For Resident 143, the admission MDS assessment was electronically signed as completed after the 14-day deadline had passed. During a later interview and concurrent medical record review, the MDS Assistant reviewed the record and verified that the admission assessment was not completed within the required timeframe.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that three of four CNA employee personnel files contained annual performance evaluations. During an interview and concurrent review of CNA 3, CNA 4, and CNA 5's personnel files with the DSD, the surveyor found that CNA 3's file showed a hire date of 6/19/12, CNA 4's file showed a hire date of 8/13/24, and CNA 5's file showed a hire date of 11/29/23. When asked to provide the most recent performance evaluations, the DSD stated he was unable to locate the prior performance evaluations for CNA 3, CNA 4, and CNA 5.
Failure to Immediately Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was immediately reported to the appropriate authorities, as required by both facility policy and state law. A resident alleged that a CNA shook their shower chair, pulled and yanked their hands, and kicked them during a shower. The resident reported this incident to other CNAs and a nurse practitioner, but there was no documentation of the allegation in the resident's medical record. The facility's policy requires immediate reporting of suspected abuse to the administrator and various agencies, but neither the Administrator nor the DON were aware of the allegation until it was reported to the state months later. Interviews revealed that the CNA involved did not report the resident's allegation, stating she did not believe the accusation was true. The DON confirmed that all staff are mandated reporters and should report any abuse allegations immediately. The failure to report the allegation in a timely manner resulted in a delay in notifying the CDPH, Ombudsman, and law enforcement, as well as a lack of internal documentation and investigation at the time the incident was alleged to have occurred. The resident had a history of moderately impaired cognition but was assessed as having the capacity to understand and make decisions.
Failure to Assess and Monitor Skin Impairment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who had a newly observed skin impairment. Upon admission and readmission, the resident had a history of healed bilateral lower extremity wounds and was noted to have scar tissue with hyperpigmentation. Despite documentation by a nurse practitioner of trace erythema and a blister on the right lower extremity on multiple occasions, licensed nurses repeatedly documented that there was no skin breakdown in the weekly summaries. Additionally, a CNA documented areas of concern on the resident's lower extremities during a daily body check, which was signed by a licensed nurse. There was no evidence in the medical record that a licensed nurse assessed the resident's bilateral lower extremities following the CNA's documentation of skin concerns. The treatment administration record did not show any treatment or monitoring orders for the resident's lower extremity wounds, and no care plan problem was initiated for the documented blister. Interviews with staff confirmed that the expected process was for CNAs to report new skin issues to licensed nurses, who would then assess, document, notify the physician, and initiate monitoring and care planning as needed. However, this process was not followed in this case. The Director of Nursing and other staff acknowledged that there should have been a care plan and monitoring for the resident's blister, and that the required assessments and documentation were not completed. The failure to assess, document, and monitor the resident's skin impairment represented a lapse in providing quality care according to the facility's policies and procedures.
Failure to Perform Required Braden Scale Assessments for Pressure Injury Progression
Penalty
Summary
The facility failed to ensure that Braden scale risk assessments were performed as required for a resident with a pressure injury. According to the facility's policy, risk assessments should be conducted weekly for the first four weeks, upon significant changes in condition, or as often as needed based on the resident's status. Medical record review showed that a resident, who lacked capacity to make decisions, was readmitted and subsequently developed a Stage 1 pressure injury that progressed to Stage 2 and later to Stage 3. Documentation confirmed the progression of the wound, but there was no evidence that repeated Braden scale assessments were completed at the time of these changes. Interviews with facility staff, including an LVN and the DON, confirmed that Braden scale assessments were not performed when the resident's pressure injury advanced from Stage 1 to Stage 2 and then to Stage 3. The LVN stated that Braden assessments were only done upon admission and not when there was a change in the wound's condition. The DON verified that the required assessments were missed during the periods when the resident's skin condition changed.
Failure to Develop Care Plans for Residents After Falls
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address specific injuries for two residents following unwitnessed falls. For one resident, who lacked capacity to make decisions, a laceration to the right temporal area was documented after an unwitnessed fall. Despite this change in condition, there was no care plan created to address the laceration prior to the resident's transfer to an acute care hospital. Both the RN and DON confirmed that a care plan should have been initiated but was not present in the medical record. Similarly, another resident, also lacking decision-making capacity, sustained a skin tear to the left forearm after an unwitnessed fall. The medical record review and staff interviews confirmed that no care plan was developed to address the skin tear. The LVN and DON both acknowledged that a care plan should have been initiated following the incident, but it was not completed. These findings were based on interviews, medical record reviews, and review of facility policies and procedures.
Inaccurate Fall Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding documentation of falls. According to the facility's policies, nursing staff are required to identify and document resident risk factors for falls and maintain complete and accurate records. For one resident, the medical record review showed a discrepancy: although the resident experienced an unwitnessed fall, the Fall Risk Assessment form indicated that there had been no falls in the past three months. This was inconsistent with other documentation, such as the SBAR Communication Form, which recorded the fall. During interviews, both a registered nurse and the Director of Nursing confirmed the inaccuracy in the Fall Risk Assessment. They acknowledged that the assessment should have reflected the fall by indicating one to two falls in the past three months, rather than none. The failure to accurately document the fall in the resident's assessment resulted in an incomplete and inaccurate medical record, contrary to the facility's own policies and accepted professional standards.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident receiving aripiprazole, an antipsychotic medication, was properly monitored for side effects as required by facility policy. The policy stated that nursing staff should monitor and report side effects of antipsychotic medications to the attending physician. Review of the resident's medical record, including the Medication Administration Record (MAR) and care plan, showed that while the resident was administered aripiprazole as ordered for psychosis, there was no documentation of monitoring for medication side effects. The resident in question had a diagnosis of psychosis and was noted to have fluctuating capacity to understand and make decisions, but was assessed as cognitively intact and exhibited no behavioral symptoms such as physical or verbal aggression. The baseline care plan included interventions to monitor for adverse effects and behavioral manifestations, with instructions to notify the physician as needed. Despite these documented interventions, there was no evidence in the MAR or other records that monitoring for side effects of aripiprazole was performed or documented, as confirmed by the Director of Nursing.
Failure to Timely Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure the timely reporting of a staff-to-resident abuse allegation involving one resident. According to the facility's policy, allegations of abuse must be reported immediately, defined as within two hours if abuse or serious bodily injury is involved, or within 24 hours otherwise. In this case, a resident with moderate cognitive impairment reported that a CNA sat next to her, put his arms around her, and touched her in a way that made her feel uncomfortable and violated. The incident was reported by the resident to an RN, who then informed the DON, SSD, and Administrator on the same day the incident occurred. Despite the internal reporting, the facility did not submit the required SOC 341 report to the state licensing agency until six days after the incident was reported by the resident. Documentation shows the incident was reported to the CDPH, L&C Program on 4/10/25, even though the resident reported the event on 4/4/25. The delay in external reporting did not align with the facility's own policy and regulatory requirements for timely notification of authorities regarding abuse allegations.
Sanitary Failures in Food Storage, Equipment Maintenance, and Chemical Sanitization
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by improper labeling and dating of food items, failure to discard expired foods, and inadequate maintenance of kitchen equipment. During an initial tour of the kitchen, surveyors observed multiple food items in the walk-in refrigerator, freezer, and on counters that were either missing use-by dates, lacked labels, or were expired. Items included eggs, sour cream, jello, sandwiches, ham, ground meats, waffles, and juice containers, many of which were not properly labeled or dated. The facility's policies required all foods to be labeled and dated, but these procedures were not followed, as confirmed by staff interviews. Further observations revealed that kitchen equipment was not maintained in good condition. The plate lowerator had loose handles and dried food debris, the can opener had a chipped blade, and plate domes were warped and corroded. Additionally, the residents' refrigerator contained several food items brought in by visitors that were not labeled with use-by dates or were undated, and the residents' microwave was found to have dried, crusted food residue on its interior surfaces. These findings were verified by dietary and support staff during the survey. The facility also failed to ensure that kitchen staff correctly tested the chemical concentration of the quaternary sanitizing solution used for food contact surfaces. A dietary aide demonstrated improper testing technique by dipping the test strip for only one second instead of the required ten seconds, potentially resulting in inaccurate readings. All of these failures were acknowledged by facility staff and had the potential to cause foodborne illnesses among the medically vulnerable resident population who consumed food prepared in the kitchen.
Infection Control Deficiencies and Lapses in Standard Precautions
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as outlined in its policies and procedures. The Infection Prevention and Control Surveillance Log contained inaccurate documentation, with the 'Meet McGeer Criteria' column incorrectly marked as 'N/A' for several entries, rather than 'Yes' or 'No' as required. Both the Infection Preventionist (IP) and Director of Nursing (DON) acknowledged these errors, which could lead to confusion among staff regarding the identification of true infections. Laundry staff were observed reusing dirty gowns multiple times per day, hanging them in close contact with other used gowns, and storing personal belongings such as lunch bags and jackets inside clean linen carts. The Housekeeping Manager and IP confirmed these practices, noting that the gowns should not be reused or stored in a manner that allows cross-contamination, and that personal items should not be kept with clean linen due to the risk of contamination. Several lapses in resident-specific infection control were also identified. One resident with a pending Clostridium difficile test and a history of the infection was not placed on contact isolation precautions, and brown stains were observed on the shared toilet. Two residents with central lines were not placed on Enhanced Barrier Precautions (EBP) as required, with no signage or PPE supplies present. Staff were observed failing to change gowns between residents and transferring potentially contaminated items, such as a tissue box, between residents on EBP and those not on precautions. These failures were acknowledged by facility leadership and posed a risk for the transmission of communicable diseases.
Failure to Ensure Proper Use of Low Air Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of new pressure ulcers and promote healing of an existing pressure ulcer for a resident at high risk. The resident, who was bedbound and unable to reposition independently, had a Stage 3 pressure injury on the right heel and required substantial assistance for mobility. The care plan and physician orders specified the use of a low air loss (LAL) mattress, with daily checks to ensure the appropriate setting according to the resident's weight and comfort. Observations revealed that the LAL mattress was repeatedly left on the static setting when care or repositioning was not being rendered. The static mode is intended to provide a firm surface for transfers or repositioning and should only be used during such activities. Staff interviews confirmed that both licensed nurses and CNAs were responsible for ensuring the mattress was set correctly, but there were lapses in checking and adjusting the settings. One CNA admitted to sometimes forgetting to check the mattress settings and only verifying that the device was powered on, not whether it was in the correct mode. The failure to return the LAL mattress to its alternating pressure mode after care resulted in the resident not receiving the intended pressure-relieving benefits of the mattress. This was contrary to the facility's policy and the physician's orders, which emphasized the importance of pressure reduction surfaces and regular monitoring to prevent further skin breakdown and promote wound healing.
Failure to Ensure Safe Smoking Practices and Fall Prevention
Penalty
Summary
The facility failed to ensure safe smoking practices and adequate fall prevention measures for several residents. Three residents who smoked were not accurately or thoroughly assessed to determine if they could safely store their own cigarettes or lighters. Despite being assessed as requiring supervision while smoking or having a history of non-compliance with the facility's smoking policy, these residents were permitted to keep cigarettes, lighters, and other smoking materials in their possession. Observations confirmed that residents smoked in non-designated areas without staff supervision and kept their own smoking materials, contrary to facility policy and their care plans. Interviews with staff and review of medical records verified that these residents required supervision and should not have had access to smoking materials independently. Additionally, the facility failed to ensure accurate fall risk assessments and the development of appropriate care plans for two residents. One resident's admission assessment inaccurately recorded their fall risk as zero, despite multiple diagnoses that increased their risk, such as difficulty walking, muscle weakness, schizophrenia, epilepsy, and Parkinson's disease. The nurse responsible for the assessment admitted to entering incorrect information, and the Director of Nursing confirmed that the resident should have been identified as at risk for falls and had a fall prevention care plan developed. However, no such care plan was in place prior to the resident experiencing a fall. Another resident, who was cognitively impaired and had a history of falls, was not provided with a care plan addressing their high risk for falls upon readmission or after subsequent falls. Medical record review and staff interviews confirmed that no fall care plan was developed during the resident's stay, and a care plan was only initiated after the resident had expired. These failures were acknowledged by facility leadership and posed risks of injury from falls and fire to the residents involved.
Failure to Document and Label IV Access Sites According to Policy
Penalty
Summary
The facility failed to provide necessary care and services related to intravenous (IV) access for four residents, including both sampled and nonsampled individuals. Specifically, for two residents with peripherally inserted central catheters (PICC lines), the facility did not obtain or document baseline measurements of the external catheter length and arm circumference upon admission, as required by physician orders and facility policy. Additionally, there was no evidence that care plans were formulated to address the use of PICC lines for these residents. Medical record reviews confirmed the absence of required documentation, and staff interviews verified these omissions. For two other residents with peripheral intravenous (PIV) lines, the facility failed to ensure that the IV sites were labeled with the date, time, and licensed nurse's initials, as required by facility policy and standard practice. Observations showed that the PIV dressings were not properly labeled, and this was confirmed by both nursing staff and the Director of Nursing (DON) during interviews. Physician orders for these residents included instructions for IV medication administration and site rotation, but the required documentation and labeling were not present in the medical records. Throughout the investigation, staff members, including an RN and the DON, acknowledged the lack of baseline measurements, missing documentation, and improper labeling of IV sites. These failures were identified through direct observation, medical record review, and staff interviews, and were confirmed to be inconsistent with the facility's own policies and procedures for IV therapy and PICC line management.
Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to four residents by not adhering to established policies and procedures regarding oxygen and nebulizer equipment. For one resident, oxygen tubing and mask were found on the floor, unlabeled, and without a physician's order or care plan for oxygen use. Additionally, there was no posted signage indicating oxygen use on the doorway, as required by facility policy. Another resident's oxygen tubing and mask were stored in a clear plastic bag but were not labeled or dated, and there was also no posted oxygen signage on the doorway, despite an active physician's order for oxygen administration. A third resident's nebulizer tubing was observed on the floor, undated, and not stored in a clear plastic bag when not in use, even though there was a physician's order for nebulizer treatments. For a fourth resident, the nasal cannula tubing was touching the floor, and the nebulizer tubing was undated and not properly stored in a clear plastic bag. This resident had physician's orders for both continuous oxygen and nebulizer treatments. In all cases, staff interviews confirmed the observations and acknowledged that the equipment should have been labeled, dated, and stored according to policy, and that appropriate signage should have been posted. Medical record reviews further revealed missing physician's orders and care plans for oxygen use in at least one case, and staff verified these deficiencies during interviews. The facility's policies required labeling, dating, proper storage of respiratory equipment, and visible signage for oxygen use, but these procedures were not followed for the affected residents.
Failure to Provide Appropriate Pain Management and Documentation
Penalty
Summary
The facility failed to provide appropriate pain management for two residents who required such services. For one resident with a history of a displaced intertrochanteric fracture of the left femur, the facility did not administer pain medication according to the physician's order, as Norco was given for a pain level of 6 when the order specified it should be administered for severe pain at a level of 7-10. Additionally, there was no care plan developed to address this resident's pain or the use of Norco, despite the resident reporting ongoing pain and receiving pain medication. For another resident with a fracture of the neck of the left femur and a history of left hip surgery, the facility failed to accurately document pain monitoring and did not administer pain medication according to the physician's order. Norco was administered for a pain level of 6, which was outside the ordered parameters. The facility also failed to ensure non-pharmacological pain interventions were provided and documented prior to administering pain medication, as required. Documentation inconsistencies were noted, with pain levels recorded as 0 during shifts when pain medication was administered for higher pain levels, and non-pharmacological interventions were marked as not applicable without explanation or documentation of refusal. Both residents lacked care plans addressing their pain and the use of high-risk medications such as Norco, contrary to facility policy. Interviews with nursing staff and the DON confirmed these findings, including the absence of required care plans, improper documentation, and failure to follow physician orders for pain management and monitoring.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for several residents, as evidenced by discrepancies in controlled drug records, lack of pain assessments, improper medication administration, and incomplete documentation. For two residents, the Controlled Drug Record for hydrocodone-acetaminophen did not match the Medication Administration Record (MAR), and there was no documentation of pain assessments before and after administration, nor evidence of non-pharmacological interventions prior to giving the narcotic medication. These findings were verified by facility staff during medication cart inspections and medical record reviews. Another resident receiving insulin injections did not have injection sites rotated as required by the care plan, with repeated administration to the same abdominal quadrants on multiple occasions. This was confirmed through review of the Location of Administration Report and the resident's care plan, which specified site rotation as an intervention. Additionally, a medication administration observation revealed that a nurse failed to instruct a resident to chew an aspirin 81 mg chewable tablet, and there was no documentation of physician notification or order clarification when the resident was unable to chew the medication, as required by facility policy. Further deficiencies included missing documentation for the administration of famotidine for one resident, with the MAR lacking evidence of administration on a scheduled date and a delayed entry made weeks later. Another resident's insulin glargine was held on multiple dates due to vital signs being outside parameters, but there was no physician order specifying these parameters, nor were there progress notes or documentation of physician contact regarding the held doses. These findings were acknowledged by facility leadership during interviews.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in medication storage and labeling practices within the facility. A pack of hydrocodone-acetaminophen tablets prescribed to a discharged resident was found stored in the IV cart, with the Controlled Drug Record indicating the medication had not been properly removed or destroyed after the resident's discharge. Additionally, four Calmoseptine ointments were discovered in a treatment cart without expiration or received dates, and the nurse confirmed that the ointments should not have been kept since their receive date was unknown. Two unlocked medication disposal bins containing undissolved tablets, sharps containers, liquid medication bottles, nasal spray containers, and insulin pens were also observed, indicating a lack of secure storage for medications awaiting disposal. Further observations revealed a bottle of Pro-Stat Advanced Wound Care supplement with sticky brown residue on and around the cap and bottle, which was verified by the nurse as not being cleaned after use as required by facility policy. Interviews with nursing staff and the DON confirmed that licensed nurses were responsible for maintaining the cleanliness, storage, and labeling of medications in their assigned carts, and that these expectations were not met in the instances observed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3,544 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Ana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Foothill Regional Medical Center D/p Snf | 1.2 mi | ★★★★★ | 12 | 0 |
| The Hills Post Acute | 1.2 mi | ★★★★★ | 29 | 0 |
| French Park Care Center | 1.3 mi | ★★★★★ | 51 | 0 |
| Town & Country | 2.2 mi | ★★★★★ | 27 | 0 |
| Healthbridge Children's Hospital - Orange D/p Snf | 2.6 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.