Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Alamitos West Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to Report Abuse Allegation: A cognitively intact resident alleged that a CNA made threatening remarks about call light use and later gave him the middle finger after he asked for hand hygiene before feeding. The allegation was reported internally, but SOC 341 was not submitted and the abuse was not reported to CDPH, the Ombudsman, or law enforcement on the day it was brought to staff’s attention; the DON stated the IDT did not submit the report because the incident did not occur on the same day it was reported.
Surveyors found that the facility did not consistently implement Enhanced Barrier Precautions (EBP) and proper catheter practices for two residents with indwelling urinary catheters. One resident’s room initially lacked EBP signage and documentation of EBP orders, and although the care plan called for EBP, an LVN later performed catheter care wearing only gloves instead of both gown and gloves as indicated. Another resident’s catheter drainage tubing was observed touching the floor, and despite care plan interventions for EBP and physician orders for Foley care, there was no EBP order or visual indicator (orange dot) by the door to show that EBP had been implemented. These failures were cited as having the potential for cross-contamination and spread of infectious organisms.
A resident with Parkinson’s disease and bilateral ankle contractures was discharged to a board-and-care setting without the facility fully completing the required discharge planning process. Although a physician ordered that the resident could go to a board and care with PT evaluation and HH, and a written Notice of Proposed Transfer/Discharge documented that notice was given to the resident and representative and mailed to the Ombudsman, the medical record lacked documentation that the Ombudsman was actually notified as required. Facility policy called for Ombudsman notification 30 days prior to a facility-initiated discharge, but the DON acknowledged this did not occur, and no discharge care plan was developed for the resident.
A resident with documented decision-making capacity was left unattended outside while waiting for family transportation to a medical appointment. After accompanying the resident outside following lunch, a CNA left the resident alone when the resident repeatedly asked to be left, positioning herself just inside the facility door instead of remaining with the resident. The DON later stated the CNA was expected to stay with the resident until the family arrived, demonstrating a failure to provide adequate supervision to prevent accidents.
A resident receiving carbidopa-levodopa for Parkinson’s disease had two duplicate physician orders with different dates for the same dose and time recorded on the MAR. An LVN confirmed administering the medication and acknowledged that the duplicate orders should have been clarified with the physician but were not. The DON verified the inaccurate, duplicate orders in the medical record, resulting in an inaccurate MAR for the resident’s Parkinson’s medication.
Delayed response to resident call lights led to unmet needs for several residents. A resident with incontinence and generalized weakness waited 20 to 40 minutes for a diaper change, while other residents reported waiting over an hour for help with repositioning, bed linens, pain medication, and incontinence care. One resident said she was not changed from 2230 until 0600, and another said staff did not answer until she and her roommates started yelling. The facility’s call light policy required staff to answer within a reasonable time and respond to the resident’s request.
Two residents receiving antipsychotic medications were not monitored as ordered. One resident on risperidone had orthostatic BP documentation that showed the same readings across positions, while another resident on Seroquel had incomplete orthostatic BP entries and no monitoring documented for visual hallucinations. The MAR also showed behavior monitoring for sudden anger outbursts with nonpharmacologic interventions documented even when zero episodes were recorded.
A resident with a right clavicular fracture was repeatedly observed without the ordered right arm sling, despite a physician order for the sling to be worn at all times except during shower and ADL care. In a separate case, a resident with dysuria, urinary frequency, urgency, and foul-smelling urine had UA/C&S results showing contamination and later E. coli, but the physician was not timely notified and the record lacked documented ongoing nursing assessment of the resident’s continued urinary symptoms.
A resident with a pressure injury did not receive wound treatment as ordered, another resident’s coccyx-to-buttock wound was not documented with weekly skin evaluations or IDT skin review and the ordered dressing care was not shown as given for the full treatment period, and a third resident’s LAL mattress was observed set at 125 pounds despite a documented weight of about 80 to 81 pounds. Staff and the DON confirmed the expected wound monitoring and mattress setting practices.
A resident with dysphagia related to a CVA, no decision-making capacity, and severely impaired cognitive skills had repeated falls documented in the care plan. The facility did not complete a post-fall Fall Risk Evaluation after one fall and entered inaccurate fall history and risk information on later evaluations, including incorrect fall counts and omission of predisposing conditions used to guide fall interventions.
A resident receiving hemodialysis had incomplete dialysis communication forms, with missing documentation for lumen count and access-site findings, and the bedside emergency dialysis kit did not include clamp scissors. The resident also had a 1000 ml/day fluid restriction, but intake records showed multiple days above the ordered limit. The ADON, IP, and facility leadership acknowledged the findings.
Medication administration did not match physician orders for three residents. One resident who was NPO and receiving meds via GT had a vitamins-minerals tablet ordered PO but given via GT without physician verification of the route. Two residents with HTN and severely impaired cognition had BP meds documented as given outside ordered hold parameters: metoprolol was charted as held despite BP/HR being within limits, and amlodipine was administered even when BP was below the family-requested threshold.
A resident with no decision-making capacity had active orders for allopurinol and aspirin, and the consultant pharmacist noted very low platelets and asked that the MD be informed, with caution for bleeding and bruising. The record did not show documented monitoring for bleeding and bruising, and an RN stated she reviewed the MRR but did not document notifying the primary or hospice physician of the recommendation.
Medication Error Rate Exceeded Threshold: The facility’s medication error rate was above the required limit. An LVN administered eye drops to a resident but did not apply pressure to the tear duct or wipe the eye area right away, and another LVN gave metformin to a resident without food even though the order and bubble pack indicated it should be taken with meals.
Medication storage and controlled substance handling were not properly maintained. For one resident, the hydromorphone controlled drug record did not match the MAR, and the DON confirmed missing and inaccurate documentation. In the med room and med carts, house supply meds were stored with other products, expired items remained in a cart, and several medications were improperly labeled or stored, including an opened refrigerated product kept unrefrigerated and a nasal spray without an open date.
Puree Recipe Not Followed During Food Preparation: A dietary aide did not follow the facility’s herb mashed potatoes recipe when preparing pureed food for residents. The aide mixed mashed potato powder, margarine, and sour cream in hot water, but did not simmer the mixture or add milk, salt, or dried oregano as directed. The RD verified the findings, and facility leadership acknowledged the issue.
Kitchen Food Safety and Sanitation Deficiencies: Surveyors observed a food prep sink without an air gap, multiple utensils and equipment items with food residue or discoloration, undated food items, frozen food past its best by date, and a dishwasher with facial hair exposed instead of a beard restraint. Staff also reported washing cantaloupes with gloved hands rather than using a brush. The DSS verified the findings, and facility leadership acknowledged them.
Failure to Educate on Safe Handling of Outside Food: The facility did not implement its policy for food brought in by family or visitors. Staff reported that outside food was not checked against residents’ diet orders, and multiple nurses and the DSD denied providing education on safe food handling, storage, or safe temperatures. A family member brought a hamburger and chocolate shake to a resident without checking it in, and stated she had not been educated by the facility. Leadership acknowledged the handout was given to the resident or responsible party, but not to visitors.
Staff failed to follow infection control practices during COVID-19 isolation, EBP care, and routine resident contact. An RN/LVN and CNA exited a COVID-19 positive room without an N95, an exposed ice scooper was left uncovered in a hallway, a CNA emptied a Foley bag without a gown, and another CNA repositioned a resident on EBP without a gown and then handled a lunch tray without hand hygiene after glove removal. The facility also did not include a resident with dysuria, urinary frequency, and burning in infection surveillance despite ongoing UTI symptoms and contaminated urine testing.
A resident with neurogenic bladder and an indwelling Foley catheter was observed multiple times with the urinary drainage bag hanging uncovered on the side of the bed instead of being placed inside a privacy bag. CNA and Case Manager both verified that the bag should be covered to provide privacy and dignity, and the facility’s policy required the drainage bag to be covered with a privacy bag.
Failure to Obtain Advance Directive Copy: The facility did not obtain and maintain a copy of a resident’s advance directive in the chart, despite documentation showing fluctuating decision-making capacity, severely impaired cognition, and a POLST with DNR/selective treatment/no tube feeding. The resident’s responsible party indicated advance healthcare directives existed, but the advance directive type and date received were left blank, and the record lacked documentation of timely attempts to secure the document.
Inaccurate MDS Fall History Coding: A resident with no capacity to make decisions was found on the floor in her room and sent to the ER, but the MDS for re-entry coded no falls in the prior month. The MDS Coordinator verified the resident should have been coded for a fall, and the DON stated MDS assessments guide the specific care provided to each resident and should be accurately coded.
A resident’s PASRR Level I screening was not accurately updated after admission when later records showed psychotropic use and a diagnosis of unspecified psychosis. The hospital-completed PASRR had marked serious mental illness as No, while the facility’s ADON verified it should have been marked Yes and that a reassessment and updated PASRR should have been submitted.
Respiratory Equipment Not Dated or Labeled: A resident receiving continuous O2 via nasal cannula and scheduled nebulizer treatments was observed with oxygen tubing and nebulizer equipment that were not dated or labeled. Central Supply staff confirmed the equipment was not dated or labeled and stated the tubing and nebulizer were typically changed and labeled weekly.
Inaccurate Documentation of Turning/Repositioning Record: A CNA documented a resident’s turning/repositioning task record inaccurately by marking N/A when the resident reportedly refused care, did not feel like being turned, or preferred a specific shift to reposition him. The DON stated N/A was only appropriate when the resident was not in the room, bed, or was out of the facility, and refusals should be documented elsewhere and reported to the charge nurse.
A facility failed to ensure an Arbitration Agreement was explained in a way understood by the resident or representative for two residents. One resident’s H&P documented no capacity to understand and make decisions, yet the resident signed a binding arbitration form that waived court rights for malpractice disputes. Another resident’s H&P documented no capacity to make decisions, but the resident also signed the Arbitration Agreement. The Admissions Coordinator stated residents without capacity should not sign and that the POA or Responsible Party should be contacted instead.
A resident with Parkinson's disease and significant mobility limitations was not repositioned every two hours as ordered by the physician. Staff interviews and observations confirmed that the resident remained on his back for extended periods, with repositioning not performed according to the care plan. Instead, staff adjusted pillows or pulled the resident up in bed, contrary to the specific physician's order.
A resident's medical record was found to be incomplete and inaccurately maintained, with missing documentation by licensed nurses for several physician-ordered treatments and interventions, including oral hygiene, skin care, and use of assistive devices. Despite documentation indicating oral care was provided, both the resident and a CNA confirmed it was not done. The DON verified these deficiencies.
Facility staff did not follow infection control procedures by leaving a used glove on the sink and toilet tank and a soiled towel on the floor in a shower room, instead of disposing of them properly in designated containers, as confirmed by the Account Manager and DON.
Three shower rooms were found to be inadequately cleaned and disinfected, with a resident reporting the appearance of fecal matter in the showers. Observations revealed dark brown residue on shower heads and brown stains on the walls and shower head holders, which were acknowledged by facility management.
Staff did not follow Enhanced Barrier Precautions during wound care for a resident with a chronic wound. An LVN and a CNA performed high-contact care activities without donning gowns, despite posted signage and physician orders requiring both gown and gloves. The staff later acknowledged that gowns should have been worn, and facility leadership confirmed the lapse in infection control practice.
Three residents with significant care needs and fall risks were observed in bed with unlocked bed wheels. Staff, including a CNA and an LVN, confirmed the bed wheels were not locked, despite facility procedures requiring this safety measure. The residents involved had diagnoses such as dementia, hemiplegia, and immobility, and were dependent on staff for mobility and transfers.
A resident who was cognitively intact was observed repeatedly calling a CNA by name and was initially ignored, then addressed with a curt 'what' rather than a respectful response. The resident reported feeling dissatisfied and disrespected by the interaction. Staff interviews confirmed that such a response was not in line with facility policy on resident dignity.
A resident did not receive whole milk with meals as specified on their meal ticket, despite being cognitively intact and having this preference documented. Staff confirmed the omission during both breakfast and lunch, and the DSS verified that all items on the meal ticket should have been served. The issue was acknowledged by facility leadership after being brought to their attention.
A resident refused bowel management medications for three days without the physician being notified, contrary to facility policy. The resident later experienced severe pain and was transferred to the hospital, where a CT scan revealed diverticulitis with an abscess and an associated ileus or possible small bowel obstruction.
The facility failed to update elopement risk assessments for two residents with dementia, leading to inadequate monitoring and intervention. One resident exhibited increased wandering behavior, prompting the use of a Wander Guard without a reassessment. Another resident, who attempted to elope, was not assessed quarterly as required, missing critical evaluations of their elopement risk.
A facility failed to respect a resident's right to self-determination by not adhering to the requested medication schedule after the resident's return from a hospital stay. Despite previous arrangements to spread out medication administration times, the facility administered medications at an earlier time without documented justification, contrary to the resident and family's request.
A resident with moderate cognitive impairment did not receive timely care for an indwelling urinary catheter, which was inserted due to urinary retention. The facility failed to provide necessary daily catheter care until five days after insertion, despite policy requirements for continual assessment and proper handling. This lapse was confirmed by interviews with the resident, a family member, and an LVN, and acknowledged by the DON, posing a risk for catheter-associated urinary tract infections.
A resident with moderate cognitive impairment was administered docusate sodium despite having loose bowel movements, contrary to physician orders. The medication was given on multiple occasions without proper communication between staff about the resident's bowel condition, leading to unnecessary medication administration.
A resident with moderate cognitive impairment requested a bath, which was not provided on the requested day due to staffing issues. The resident expressed frustration, and facility records confirmed the bath was not documented as given. Interviews with staff and family verified the oversight.
A resident with moderate cognitive impairment experienced mild weakness and a flushed face, but the facility failed to update the care plan to address this change in condition. This oversight was confirmed by interviews with an LVN and an RN, and acknowledged by the DON.
A resident with moderate cognitive impairment received an extra capsule of psyllium on multiple occasions due to a pharmacy error. The physician's order was for one capsule twice a day, but the pharmacy delivered a bubble pack with two capsules, leading to the administration of an extra dose. The DON confirmed the error during a review.
The facility failed to ensure accurate documentation of bladder elimination for three residents with indwelling urinary catheters. CNAs inaccurately recorded these residents as incontinent, despite the presence of catheters, potentially affecting their care needs. The inaccuracies were confirmed by the DON during a review.
The facility failed to notify a physician when a resident had no bowel movements for over three days, despite having a bowel management protocol. Additionally, another resident did not receive dynamic splints as ordered, with multiple instances of non-compliance documented. These deficiencies were confirmed through interviews and record reviews.
A resident in an LTC facility was not provided with the correct toothbrush for oral hygiene, using a denture brush instead. This occurred because a CNA failed to provide the regular toothbrush, which the resident preferred and was supposed to use. Interviews with an LVN and the DON confirmed the intended use of the brushes, highlighting a failure to accommodate the resident's needs.
The facility failed to maintain sanitary conditions in the kitchen, including improper use of hair restraints by staff, inadequate labeling and dating of food items, and unsanitary kitchen equipment. Observations revealed food debris in the microwave, corroded pans, and wet plates and domes. Cutting boards were also heavily marred, and a scoop was improperly stored in a food bin, potentially risking foodborne illnesses among residents.
The facility failed to maintain infection control practices, lacking documentation for Legionella risk assessment and testing protocols. CNAs did not follow Enhanced Barrier Precautions for a resident with a Foley catheter, and personal items were improperly stored in the clean laundry area. Visitors did not adhere to contact isolation precautions, and a CNA did not change gowns between assisting two residents.
The facility failed to obtain or provide information on advance directives for several residents, leading to incomplete or missing documentation. Residents with the capacity to make decisions were not offered information on formulating advance directives, and some residents' directives were incomplete or not verified. This deficiency was identified through interviews and medical record reviews.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their individual care needs. A resident with severe cognitive impairment experienced a fall without a care plan being developed. Another resident on antidepressant medication and a third resident on antibiotics for an infected wound also lacked appropriate care plans. These deficiencies were confirmed by staff and acknowledged by the DON and Administrator.
The facility failed to provide adequate respiratory care for multiple residents, as evidenced by undated and unlabeled oxygen equipment, lack of proper storage, and missing care plans. Staff confirmed these deficiencies, indicating a systemic issue in equipment management and documentation.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation to CDPH, L&C Program for one of four residents reviewed for abuse. The report states that Resident 1 was cognitively intact and had been admitted and later readmitted to the facility. On 4/23/26, CNA 3 allegedly told Resident 1 that if he pressed the call light or called out for help, staff would not come and no one else would come, and the same CNA allegedly gave Resident 1 the middle finger after the resident asked the nurse to wash hands before feeding. The facility record did not show that SOC 341 was submitted on the day the allegation was reported to staff, and the allegation was not reported to CDPH, the Ombudsman, or law enforcement that day. Facility interviews showed the allegation was reported internally to the IP and SSD on 4/24/26, and the SSD confirmed SOC 341 was not submitted. Resident 1’s son had also called the nurse to complain that CNA 3 had previously flipped off his father and was still assigned to him. The DON acknowledged the facility did not report the alleged abuse to CDPH, the Ombudsman, or law enforcement on 4/23/26 and stated the IDT team did not submit SOC 341 because the incident did not happen on the day it was reported. The facility completed a grievance report on 4/24/26.
Failure to Implement Enhanced Barrier Precautions and Proper Catheter Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control practices, including Enhanced Barrier Precautions (EBP), for residents with indwelling urinary catheters. CMS QSO-24-08-NH and the facility’s own IPCP policy require EBP, including gown and glove use during high-contact resident care activities such as catheter care, and clear signage to indicate required PPE. Surveyors observed that, although an isolation cart with gowns and gloves was present near one resident’s room, there was initially no EBP signage posted outside the room, and the resident’s medical record did not contain a physician’s order or documentation showing the resident had been placed on EBP related to the indwelling urinary catheter. For Resident 2, who had an indwelling urinary catheter with physician orders for Foley catheter management and a care plan intervention specifying the use of EBP, the facility did not have a corresponding physician’s order or documentation that EBP had been implemented at the time of the initial review. During observations, a CNA confirmed the presence of the catheter and that CNAs were responsible for catheter care, but had not yet provided hygiene care. Later, after EBP signage and an orange dot indicator were present at the door, an LVN acknowledged that these indicators signaled the need for gown and glove use for high-contact care such as catheter care. However, when the LVN performed catheter care for Resident 2, the LVN wore only gloves and did not don a gown, contrary to the facility’s EBP expectations and signage. For Resident 3, surveyors observed an indwelling urinary catheter with drainage tubing touching the floor, and a CNA confirmed this observation. The CNA stated that treatment nurses were responsible for catheter care. Resident 3’s physician orders included Foley catheter care every shift and catheter management instructions, and the care plan also identified the use of EBP as an intervention for the indwelling catheter. Despite this, the medical record did not contain a physician’s order or documentation that EBP had been implemented for Resident 3, and there was no orange dot indicator by the resident’s name on the door to signify EBP status. The QIC/IP later verified that EBP should be in place for residents with medical devices such as indwelling urinary catheters and confirmed that EBP orders and indicators for these residents had not been in place at the time of the initial observations. The report states these failures had the potential for cross-contamination and spread of infectious organisms in the facility.
Failure to Complete Required Discharge Planning and Ombudsman Notification
Penalty
Summary
The facility failed to complete the discharge planning process for one of three sampled residents by not providing required notifications and not developing a discharge care plan. Facility policy titled “Admission, Transfer and Discharge” (revised 4/2025) requires that residents not be transferred or discharged unless specific criteria are met and that written notice of transfer or discharge, including reasons and appeal rights, be provided to the resident and representative, with a copy sent to the State Long-Term Care Ombudsman at least 30 days in advance except in limited circumstances. The policy also requires that, when a transfer or discharge is necessary because the resident’s needs cannot be met, the physician document the basis for transfer and the specific needs and services involved. Resident 1, who had Parkinson’s disease and contractures of both ankles, was admitted to the facility on an unspecified date and later had a physician order dated 1/30/26 stating it was acceptable for the resident to go to a board and care if acceptable to the family and resident, and that the resident may go with PT evaluation and home health. A Notice of Proposed Transfer/Discharge for this resident, dated 2/2/26, documented that the notice was provided to the resident and the resident representative on that date, that the notice was mailed to the Long-Term Care Ombudsman on that date, and that the reason for discharge was that the resident’s health had improved sufficiently so that facility services were no longer required. The notice also indicated that notice was given as soon as practicable. However, review of Resident 1’s medical record did not show documented evidence that the Ombudsman was notified of the resident’s discharge as required by facility policy, and the DON confirmed during interview that the notice of transfer/discharge should have been provided to the Ombudsman 30 days in advance. Additionally, review of Resident 1’s care plans showed no care plan developed for a discharge plan, and the DON verified that a discharge plan care plan was not developed for this resident. These inactions constituted a failure to ensure the discharge planning process was thoroughly completed for Resident 1.
Resident Left Unattended Outside While Awaiting Transportation
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and that adequate supervision was provided when a resident was left unattended outside while waiting for transportation to a medical appointment. The resident, who had decision-making capacity per a history and physical dated 10/18/25, was scheduled to be picked up by family for a doctor's appointment. On the day of the incident, after the resident’s lunch, CNA 4 accompanied the resident outside the facility to wait for the family. During this time, the resident repeatedly told CNA 4 to leave him. CNA 4 reported that she left the resident alone outside to give him space, remaining just inside the door rather than staying with him. The DON later confirmed that CNA 4 was expected to remain with the resident until the family arrived, indicating that the resident had been left unattended in violation of supervision expectations. This sequence of events, as identified through complaint intake, medical record review, and staff interviews, formed the basis of the deficiency for failure to provide necessary care and services to ensure adequate supervision and prevent accidents for one of four sampled residents.
Duplicate Parkinson’s Medication Orders Not Clarified on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for a resident receiving carbidopa-levodopa for Parkinson’s disease. The facility’s policy on Medication Administration requires that all current drugs and dosage schedules be accurately recorded on the MAR and that licensed or otherwise authorized staff prepare, administer, and record medications. For this resident, the Order Summary Report showed a physician’s order dated 1/14/26 for carbidopa-levodopa 25-100 mg, two tablets by mouth daily. However, review of the January 2026 MAR revealed two active physician orders for the same medication and dose, one dated 11/25/25 and another dated 1/14/26, both scheduled for administration at 0900. During an interview and concurrent record review, an LVN confirmed that she administered carbidopa-levodopa 25-100 mg, two tablets at 0900, and verified that there were duplicate orders with different dates on the MAR. She stated that she should have clarified these duplicate orders with the resident’s physician but had not done so. In a separate interview and concurrent record review, the DON also verified the presence of the duplicate orders and the inaccuracy in the medical record. The report states that this failure had the potential for the resident’s care needs not being met because the medical information was inaccurate.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure residents’ needs were accommodated in a timely manner for five residents, including four sampled residents and one nonsampled resident, when call lights were not promptly answered. The facility policy titled Call Light/Bell stated staff should answer the light/bell within a reasonable time and respond to the resident’s request, and if the item was not available or staff were unable to assist, they should explain to the resident and notify the charge nurse for further instructions. Resident 146, who had bowel and bladder incontinence related to generalized weakness, stated she had been waiting about 20 minutes for a diaper change and later said she had waited almost 40 minutes for assistance. She reported that a staff member had turned off her call light, but she did not know who it was, and she said she had at times waited more than 45 minutes for diaper changes or other needs. The record showed her care plan included checking for incontinence as required, washing and drying the perineum, and changing clothing as needed after incontinence episodes. During the observation, LVN 4 said the assigned CNA was busy assisting another resident with a shower and had requested a break, and CNA 5 later provided the diaper change. Resident 8 stated she waited more than an hour for the call light to be answered when she needed repositioning and bed sheets fixed, and later said she felt terrible because staff took at least an hour and a half to respond when she pressed the call light because she had a wound on her buttock and needed to be readjusted. Resident 14 stated she and her roommates pressed the call light at the same time and had to start yelling because no one came, and she said she needed pain medication at 1900 hours. Resident 37 stated she waited over an hour for the call light to be answered and even called the front desk. Resident 141 stated she asked to be changed at 2230 hours and was not changed until 0600 hours the next morning, and she said she had complained that call lights were not answered right away. The Administrator, DON, and Nurse Consultant were informed of and acknowledged these findings.
Unnecessary Psychotropic Medication Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure two residents receiving psychotropic medications were monitored as ordered. Resident 13, who had no capacity to understand and make decisions and was documented with moderately impaired cognition, was prescribed risperidone for psychosis manifested by suspicion that her roommate was harming her. The physician also ordered weekly orthostatic blood pressure monitoring in the lying, sitting, and standing positions, but the MAR showed readings documented as the same across positions on multiple dates, including identical values for sitting, lying, and standing or missing position-specific readings. Resident 41, who had fluctuating capacity to understand and make decisions and was documented with severely impaired cognition, was prescribed Seroquel for psychosis manifested by visual hallucinations. The physician ordered weekly orthostatic blood pressure monitoring in the lying, sitting, and standing positions, but the MAR showed incomplete or inaccurate position documentation, including readings recorded only for some positions and one entry marked N/A for sitting and standing. The MAR also showed monitoring for sudden anger outbursts every shift, with nonpharmacologic interventions documented even when zero episodes were recorded. For Resident 41, the MAR failed to show any monitoring for visual hallucinations despite the Seroquel order for psychosis manifested by that behavior. The licensed nurse confirmed that residents on antipsychotic medications should be monitored every shift for manifested behaviors and side effects, and that if behaviors were observed, the number of episodes, interventions used, and effectiveness should be documented. The DON stated that orthostatic blood pressure readings should be obtained in lying, sitting, and standing positions and should not be the same or marked N/A, and that behavior monitoring should include documentation of episodes, interventions, and effectiveness when behaviors are observed.
Failure to Follow Sling Orders and Timely Report UTI Results
Penalty
Summary
The facility failed to provide care according to physician orders for a resident with a right clavicular fracture. Resident 29 was admitted after a mechanical fall that resulted in a right clavicular fracture, and the physician ordered the resident to wear a right arm sling at all times, with removal only during shower and ADL care, and to remain non-weight bearing to the right upper extremity. The care plan also included applying the right arm sling at all times except during shower and ADL care. During multiple observations, Resident 29 was found lying in bed without the right arm sling in place. On several occasions, the resident was observed without the sling while in bed, including during repositioning and at other times when no staff were providing care. During an interview, a CNA stated she had not been informed that the resident needed to wear a sling and said the sling in the restroom had not been identified to her as belonging to the resident. A concurrent observation confirmed the resident was not wearing the sling. An LVN later reviewed the record, confirmed the physician order for the sling, and stated the resident should have been wearing it at all times except for showers, but the CNA had not asked for help applying it after the resident’s shower. The facility also failed to timely notify the physician of urinalysis results and the resident’s ongoing urinary symptoms for another resident. Resident 141 reported burning with urination, increased frequency, urgency, and foul-smelling urine, and a urine test was ordered after these symptoms were reported. Laboratory results later showed a contaminated specimen and then a positive E. coli result. The record showed repeated attempts to obtain physician response, but documentation did not show timely notification of the physician after the positive result was reported to the facility. The record also did not show documented continued monitoring or assessment by licensed nurses when the resident continued to report bladder discomfort, dysuria, frequency, and urgency. Interviews with nursing staff and the IP confirmed the delay in notifying the physician and the lack of documented follow-up after the lab results were received.
Failure to Provide Ordered Wound Care and Skin Monitoring
Penalty
Summary
The facility failed to ensure necessary care and services were provided to prevent new pressure ulcers and to promote healing of existing wounds for three residents. The report states that the facility did not administer wound treatment for Resident 8 as ordered by the physician. Resident 8 had a left ischium pressure injury, and the medical record showed a physician’s order for cleansing with normal saline, applying Medihoney and alginate dressing, and covering with a dry dressing every day shift for 30 days. A wound physician later documented a different treatment plan that included collagen powder, Medihoney, and a dry dressing, and the licensed nurse acknowledged that he did not update the treatment orders to match the wound physician’s orders even though he was aware of them. For Resident 9, the facility did not complete the weekly skin evaluations and IDT skin review for a coccyx extending to right buttock wound, and the wound treatment was not documented as administered as ordered for the full ordered period. The resident was found with a small open area to the coccyx extending to the right buttock, and the physician ordered daily wound care with normal saline, Calmoseptine cream, and a foam dressing, followed by re-evaluation. The record showed the treatment order in the September TAR, but the October TAR did not show documented evidence that the dressing treatment was administered from 9/17/25 through 9/30/25. The record also failed to show weekly monitoring and evaluation of the wound, re-evaluation after 14 days of treatment, or weekly IDT Skin Review documentation. Both an LVN and the DON confirmed that weekly skin assessment and IDT review should have been completed. For Resident 29, the facility did not ensure the low air loss mattress setting was appropriate for the resident’s weight. During observation, the mattress was set at 125 pounds while the resident’s documented weight was 80 to 81 pounds. The resident had severely impaired cognition, was at risk for pressure ulcers, and required assistance with bed mobility. The resident had a physician’s order for the low air loss mattress for skin maintenance and wound care, and the care plan addressed pressure injury prevention with use of the mattress. Staff stated the mattress setting should be based on the resident’s current weight, and the DON stated the setting should be based on the resident’s current weight or comfort level.
Incomplete and inaccurate fall risk evaluations after resident falls
Penalty
Summary
The facility failed to ensure that Resident 3 received the required fall-related services after a fall and failed to complete fall risk evaluations accurately. Facility policy stated that each resident should receive an appropriate assessment and interventions to prevent falls, that a licensed nurse should complete a physical assessment after a fall, and that a post-fall Fall Risk Evaluation should be completed. Resident 3 had a history of dysphagia related to a cerebrovascular accident, lacked capacity to make decisions, and had severely impaired cognitive skills for daily decision making. Resident 3's care plan identified a fall risk and documented that the resident was found on the floor on 7/21, 8/9, 9/1, 9/10, and 9/14/25. Review of the Fall Risk Evaluations showed inaccurate documentation, including a 7/25/25 evaluation stating the resident had no falls in the past three months despite a fall on 7/21/25, a 9/10/25 evaluation stating the resident had one to two falls in the past three months and no predisposing diseases or conditions despite more than two falls and a diagnosis of cerebrovascular accident, and a 9/14/25 evaluation stating one to two falls in the past three months despite more than two falls in the last three months. The medical record also did not show a Fall Risk Evaluation was completed after the 8/9/25 fall.
Dialysis Documentation, Emergency Kit, and Fluid Restriction Not Maintained
Penalty
Summary
Safe, appropriate dialysis care/services were not fully provided for one resident receiving hemodialysis. The resident was admitted with the capacity to understand and make decisions and had physician orders for hemodialysis on Monday, Wednesday, and Friday. Facility policy required ongoing communication and documentation related to pre- and post-dialysis care, including assessment and communication details in the clinical record. The resident’s dialysis communication forms were not accurately completed. The pre-dialysis section lacked documentation of the number of lumens on multiple dialysis dates, the dialysis center section also lacked the number of lumens on those dates, and the post-dialysis section was missing documentation of the number of lumens on one date, the access site on another date, and documentation of redness, swelling, pain, drainage, or bleeding on that same date. The ADON reviewed the record and verified these omissions, stating the charge nurse was responsible for completing the form before dialysis, upon return, and following up with the dialysis center if information was incomplete or inaccurate. The resident’s bedside emergency dialysis kit did not have clamp scissors available, although the kit did contain a tourniquet, gauze, sterile gloves, and tape. In addition, the resident had a physician order for a 1000 ml/day fluid restriction, but the fluid intake record showed multiple days when intake exceeded that limit, including 1600 ml, 1200 ml on several dates, 1320 ml, and 1440 ml. The IP verified the resident was on hemodialysis and that the fluid restriction should be maintained to ensure the resident did not go into fluid overload.
Medication Orders Not Followed for Route and Blood Pressure Parameters
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of each resident when staff failed to follow physician orders for medication administration. Facility policy stated medications must be administered as prescribed by the attending physician, and staff were expected to contact the physician if an order seemed inappropriate for the resident’s condition. The report identified three residents affected by these failures: one resident whose medication route was not verified with the physician, and two residents whose blood pressure medications were not administered according to ordered parameters. For one resident with fluctuating capacity to understand and make decisions and who was NPO because of dysphagia, a physician order dated 8/18/25 directed multiple vitamins-minerals one tablet by mouth daily. During medication observation, an LVN administered the tablet via GT. Later interview confirmed the resident could not take medications by mouth and that the route documented in the order was incorrect for the way the medication was given. The LVN stated the charge nurse was responsible for clarifying the order with the physician and informing the physician if the medication order was not appropriate for the resident’s condition. For another resident with severely impaired cognition and hypertension, the physician ordered metoprolol 25 mg twice daily and to hold it only if SBP was below 100 mmHg or HR was below 60 bpm. The MAR showed the medication was documented with a code indicating the BP was below parameters on multiple dates, even though recorded BP and HR values were within the ordered limits. For a third resident with severely impaired cognition, the physician ordered amlodipine 2.5 mg twice daily and to hold it if BP was less than 135 mmHg per family request. The MAR showed the medication was administered on multiple occasions when BP readings were below 135 mmHg, and staff verified these findings during interview and record review.
Pharmacy Recommendation Not Communicated for Resident on Aspirin and Allopurinol
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed for Resident 11, who was reviewed for unnecessary medications. Resident 11 was admitted and later readmitted to the facility, and was discharged on 9/30/25. The resident had physician orders dated 5/5/25 for allopurinol 100 mg, two tablets by mouth daily for gout, and aspirin EC 81 mg, one tablet by mouth daily for CVA prophylaxis. The resident’s H&P dated 5/7/25 stated the resident had no capacity to understand and make decisions. The consultant pharmacist’s MRR dated 8/21/25 documented that Resident 11 had very low platelets while receiving aspirin and allopurinol and stated, “Please ensure MD is aware of this level,” with additional caution for bleeding and bruising. The resident’s September 2025 order summary did not show documented monitoring for bleeding and bruising. During interview and concurrent record review on 9/30/25, RN 1 verified the pharmacy recommendation and the active orders, but stated she did not document that the primary physician or hospice physician were notified of the pharmacist’s recommendation and said she should have received MD orders to monitor for bleeding and bruising. The Administrator, DON, Nurse Consultant, and Certified Dietary Manager later acknowledged the findings.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent; the reported medication error rate was 6.67%. During a medication pass observation for Resident 107, LVN 5 administered Refresh Tears Plus Ophthalmic Solution to the resident’s right eye, but did not apply pressure to the right tear duct or wipe the tear from the eye area right away after the drop was given. The resident immediately closed the eyes and the drop was seen coming out of the eye. LVN 5 was informed of the observation and acknowledged the finding. The facility also failed to administer metformin with food as ordered for Resident 117. The physician’s order directed metformin HCl 850 mg by mouth twice daily, and the medication bubble pack indicated it was to be given with meals. During a medication pass observation, LVN 4 administered metformin without any food. Resident 117 stated she had finished her meal around 0800, and LVN 4 later stated the medication should be given with a meal or within 30 minutes of eating. LVN 4 acknowledged the resident had not received a snack after breakfast and verified the finding.
Medication Storage, Expired Drugs, and Controlled Substance Reconciliation Failures
Penalty
Summary
The facility failed to ensure proper medication storage, timely disposal of expired medications, and accurate reconciliation of controlled substances. For Resident 152, a physician’s order dated 9/22/25 authorized hydromorphone HCL 2 mg by mouth every four hours as needed for moderate to severe pain. Review of the controlled drug record showed the medication was signed off on 9/28/25 at 0328 hours and on 9/29/25 at 1120 hours, but the MAR did not contain corresponding documentation for those entries. The MAR instead showed hydromorphone administrations at 0432 hours and 2118 hours on 9/28/25, and at 0127 hours and 0759 hours on 9/29/25. During interview and record review, the DON confirmed the discrepancy and verified that the MAR was missing documentation for the controlled drug record entries, and that one controlled drug record entry was inaccurate. During inspection of Station A medication room, two bottles of house supply milk of magnesia were stored together with two boxes of hemorrhoidal suppositories, five boxes of bisacodyl suppositories, and six boxes of enemas. In Medication Cart D, two boxes of multi-function sterile red caps were found with an expiration date of 9/2025, while the pharmacy labels showed discard dates of 5/20/25 and 4/14/25. In Medication Cart C, Trelegy Ellipta for Resident 74 was stored with an unlabeled box of bisacodyl suppositories, an opened bottle of acidophilus capsules dated 9/25/25 and labeled refrigerate after opening was stored unrefrigerated, and fluticasone propionate nasal spray for Resident 60 was not labeled with an open date. Staff who inspected the carts and medication room verified these findings.
Puree Recipe Not Followed During Food Preparation
Penalty
Summary
The facility failed to ensure that 17 of 17 residents who received pureed food from the kitchen were served the proper diets because the facility's puree recipes and menu were not followed. The cited issue involved the herb mashed potatoes recipe, which was supposed to be prepared using package directions with added water, milk, margarine, salt, dried oregano, simmering time, and sour cream, but the preparation observed did not follow those directions. During observation of puree preparation, a dietary aide was seen mixing mashed potato powder, margarine, and sour cream in hot water. The aide did not simmer the herb mashed potatoes and did not add milk, salt, or dried oregano as required by the recipe. In interview, the aide confirmed the recipe was not followed and stated he should have followed it. The RD verified the findings and stated the recipes should be followed to ensure residents were receiving the proper nutrition. The Administrator, DON, Nurse Consultant, Certified Dietary Manager, and Dietary Aide also acknowledged the findings.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen met food safety and sanitary requirements during surveyor observations and interviews. During an initial kitchen tour, the two-compartment food preparation sink was observed without an air gap, and the DSS verified the finding. The report cited the facility’s backflow prevention policy and USDA Food Code guidance stating that an air gap is the most reliable backflow prevention device and is intended to prevent backflow and cross connection concerns. Surveyors also observed multiple food preparation utensils and equipment items that were not in clean, sanitary, or good working condition. These included a sauce pot with dried food particles, a sauce pot with dark discoloration, a pan with brown and black discoloration, two scoopers with dried food particles, two heavily marred green cutting boards with white discoloration, a container storing scoopers with dried food particles, and a can opener with white and brown particles. The DSS verified these findings and stated the items should be replaced to prevent particles from going into food. Additional kitchen deficiencies involved food labeling, dating, storage, staff hygiene, and produce washing practices. Surveyors observed eight containers of sherbet, one case of frozen hash browns, and one opened bag of cereal that were undated, as well as a bag of frozen English muffins with a best by date of 9/6. A dishwasher with facial hair was observed wearing a surgical mask with parts of the facial hair exposed instead of a beard restraint. Staff also reported washing cantaloupes with gloved hands in a basin and not using a brush, despite the facility policy and USDA Food Code guidance for washing fruits with tough rinds or peels. The Administrator, DON, Nurse Consultant, Certified Dietary Manager, and Dietary Aide 1 acknowledged the findings.
Failure to Educate on Safe Handling of Outside Food
Penalty
Summary
The facility failed to implement its policy regarding foods brought by family members or visitors. The policy required all outside food to be checked by dietary staff or a nurse to ensure it did not conflict with a resident’s prescribed diet, including therapeutic, texture, and fluid modifications, and that residents or representatives be given safe food handling guidance. The facility’s written guidance for families included instructions on hand hygiene, thawing raw meats safely, cooking foods to safe internal temperatures, and refrigerating food within an hour of arrival, with leftovers discarded after 72 hours. Surveyors found that staff did not educate families or visitors on safe food handling and storage of food brought from outside the facility. The DON stated families were told outside food was for one-time consumption and that there were no refrigerators available for leftover food, although a designated area in the walk-in refrigerator had been identified but not implemented. LVN 4 and RN 2 both denied educating families on safe food handling or storage, and neither could state safe food temperatures. The DSD stated she had not provided in-services on safe food handling and had not communicated with families or visitors about safe handling of outside food. During observation and interview, Family Member 1 brought a hamburger and chocolate shake to Resident 48 and did not check the food in with staff. Family Member 1 stated she had not been educated by the facility on safe food handling, storage, or food temperatures. On interview, the Administrator, DON, Nurse Consultant, Certified Dietary Manager, and Dietary Aide 1 acknowledged the facility’s handout was provided to the resident and/or responsible party, but not to visitors, and they acknowledged the findings.
Infection Control and Surveillance Failures
Penalty
Summary
The facility failed to ensure proper infection control practices were followed in a COVID-19 positive isolation room. During observation, CNA 9 and LVN 8 were seen exiting Room B, which was identified as a Red Zone and had Novel Respiratory Precaution signage posted, without wearing an N95 mask. Both staff members stated the room was for a resident who tested positive for COVID-19 and confirmed that the required PPE included a gown, gloves, N95 mask, and face shield. Both also stated they had removed their N95 masks while still inside the isolation room. The facility also failed to maintain infection control around shared equipment and resident care activities. In Hallway A, the ice scooper attached to the ice bucket was observed uncovered, with the top and bottom exposed while staff and residents walked past it. For Resident 77, who had an indwelling Foley catheter and an order for Enhanced Barrier Precautions, CNA 10 was observed emptying the catheter bag without wearing an isolation gown, despite the EBP signage and PPE cart being present outside the room. For Resident 29, who was on Enhanced Barrier Precautions due to a wound, CNA 2 was observed repositioning the resident without wearing a gown while her clothing contacted the resident during care. CNA 2 then removed her gloves, exited the room, and handled a lunch tray without performing hand hygiene after glove removal and before touching the tray. The facility also failed to include Resident 141 in infection surveillance even though the resident reported dysuria, increased urination, burning with urination, and foul-smelling urine beginning on 9/11/25, and later continued to complain of burning and urinary frequency while urine testing showed a contaminated result and repeat testing was ordered.
Failure to Cover Urinary Drainage Bag for Privacy and Dignity
Penalty
Summary
The facility failed to ensure that Resident 85 received the necessary catheter care and services by not providing a dignity bag to cover the resident’s urinary catheter drainage bag. The report states that the facility’s policy for indwelling catheter care required daily catheter care and for the drainage bag to be covered with a privacy bag. Resident 85 was admitted and later readmitted to the facility, had fluctuating capacity to understand and make decisions, and was assessed as having severely impaired cognition, neurogenic bladder, and use of an indwelling urinary catheter. During observation, Resident 85 was seen in bed with a cloudy yellow urinary drainage bag hanging on the right side of the bed without a privacy bag. The same condition was observed again later that day while staff were providing care in the room. CNA 1 stated that the urinary collection bag should be placed inside a special bag to provide privacy and dignity and verified the finding. The Case Manager also verified that the drainage bag should be covered for privacy and dignity and then placed the urinary collection bag inside the privacy bag. The Administrator, DON, and Nurse Consultant were informed of and acknowledged the findings.
Failure to Obtain and Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to follow its Advance Directives and Associated Documentation policy for one of eight sampled residents reviewed for advance directives. The policy required the facility to obtain a copy of the resident’s advance directive and any conservatorship or guardianship documents and place them in the health record. For Resident 41, the medical record showed fluctuating capacity to understand and make decisions, severely impaired cognition on the MDS, and a DNR selected in section S of the MDS POLST information. The record also showed the resident’s Advance Directive Acknowledgement form was signed by the responsible party, indicating that advance healthcare directives existed and would be followed, but the section identifying the type of advance directive and the date received was left blank. Social services documentation stated the resident had no advance directives in one assessment, while another note documented that the POLST was DNR, selective treatment, no tube feeding, and no AHCD, and that the resident was not interested in formulating one. The medical record did not contain a copy of the resident’s advance directive and did not show documentation of attempts to obtain a copy until a later social services note requesting the living will/trust from the family member.
Inaccurate MDS Fall History Coding
Penalty
Summary
The facility failed to ensure the MDS assessment was completed accurately for one resident. Resident 3 was admitted and later readmitted to the facility, and the H&P examination dated 6/26/25 showed the resident had no capacity to make decisions. A Post-Event IDT Review dated 7/22/25 documented that on 7/21/25, Resident 3 was found on the floor in her room on her stomach and left side and was taken to the emergency room shortly thereafter. However, the MDS assessment for the resident's re-entry from the short-term acute care hospital on 7/25/25 coded the resident as having no falls in the last month prior to admission/entry or re-entry. During interview and concurrent record review on 10/1/25, the MDS Coordinator verified the resident should have been coded for a fall in the last month prior to re-entry. The DON later stated that MDS assessments provide guidance for the specific care to provide to each resident and should be accurately coded.
Inaccurate PASRR Screening Not Updated for Resident With Psychosis
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed and updated for one resident reviewed for PASRR. The resident’s PASRR Level I screening, completed by the acute care hospital before admission, marked Section III for serious mental illness as No, even though the resident later had a physician order for Seroquel 50 mg by mouth every six hours as needed for psychosis and was documented to have a diagnosis of unspecified psychosis. The facility’s policy stated that PASRR is to be completed on every resident upon admission and that admissions or licensed nursing personnel will complete the Level 1 PASRR and ensure referral to appropriate state agencies for residents with ID/RC or SMI. During record review and interview, the ADON verified that if the hospital-completed PASRR contained discrepancies, the facility would update and complete the PASRR upon admission. The ADON stated Section III of the resident’s PASRR should have been marked Yes and that the facility should have completed a reassessment and submitted another PASRR with accurate and updated information. The Administrator, DON, Nurse Consultant, and Certified Dietary Manager later acknowledged the findings.
Respiratory Equipment Not Dated or Labeled
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for Resident 148 by not ensuring the oxygen tubing and nebulizer equipment were dated or labeled. Resident 148 was admitted to the facility and had physician orders for continuous oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%, as well as Ipratropium-Albuterol solution every 6 hours for bilateral pleural effusion. During observation, Resident 148 was seen receiving oxygen at 2 liters per minute via nasal cannula, and the oxygen tubing and nebulizer were not dated or labeled. In a concurrent interview and observation, Central Supply staff confirmed the equipment was not dated or labeled and stated the tubing and nebulizer were typically changed and labeled weekly. The staff acknowledged and verified the findings.
Inaccurate Documentation of Turning/Repositioning Record
Penalty
Summary
The facility failed to ensure the medical record for one resident was accurate when CNA 4 documented the resident’s turning/repositioning task record incorrectly. The facility’s documentation policy stated the clinical record must be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress, and the resident’s medical record review showed the resident had the capacity to understand and make decisions. Review of the CNA task record showed the N/A column was marked for turning/repositioning on multiple dates and times. During a concurrent interview and record review, CNA 4 stated she used N/A when the resident refused care, did not feel like being turned or repositioned, or preferred second-shift nurses to reposition him to his right side. The DON stated N/A should only be used if the resident was not in the room, bed, or was out of the facility at an appointment, and that refusals should be documented in the refusal column and reported to the charge nurse.
Arbitration Agreement Signed by Residents Without Capacity
Penalty
Summary
The facility failed to ensure the Arbitration Agreement was explained in a form, manner, and language the residents or their representatives understood for two residents reviewed. Resident 11 was admitted and later readmitted to the facility, and the H&P dated 2/17/25 documented that the resident had no capacity to understand and make decisions. Despite this, the Arbitration Agreement dated 6/4/25 was signed by Resident 11. The agreement stated that by signing, the resident gave up the right to dispute allegations of medical malpractice in court and agreed to binding arbitration for the resident and related parties. Resident 122’s record showed the Arbitration Agreement dated 5/14/25 was signed by the resident, while the H&P dated 5/16/25 documented that the resident had no capacity to make decisions. During an interview and concurrent record review, the Admissions Coordinator stated that for residents with fluctuating or no capacity, the facility communicated with the POA if one existed, or otherwise with the Responsible Party, and that residents without capacity should not sign the Arbitration Agreement. The Admissions Coordinator reviewed the signed agreements for Residents 11 and 122 and verified that neither resident should have been able to sign the Arbitration Agreement.
Failure to Follow Physician's Repositioning Order for Dependent Resident
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained or maintained their highest practical physical well-being. Specifically, the facility did not follow a physician's order to reposition the resident every two hours on the left side and every two hours on the right side while in bed. The resident, who had diagnoses including Parkinson's disease, right ankle contracture, and mobility abnormalities, was dependent or required substantial assistance for bed mobility and transfers. Observations on multiple occasions showed the resident lying on his back with the head of the bed elevated, and interviews with CNAs revealed that repositioning was not performed as ordered. Instead, staff reported only pulling the resident up in bed or adjusting pillows under his arms, rather than turning his body as specified in the physician's order. The facility's policies required that all physician orders be specific and complete, and that staff provide interventions according to individualized care plans and professional standards. Despite these policies, staff interviews indicated that repositioning was done only when the resident requested it or according to his preference to remain on his back, rather than following the prescribed schedule. The DON acknowledged that the order should have been discontinued if it was not being followed, but at the time of the survey, the order remained in place and was not being implemented as written.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as evidenced by missing documentation on the Treatment Administration Record (TAR) for multiple physician-ordered treatments and interventions. Specifically, there were no entries from licensed nurses for several ordered tasks, including application of fluocinonide cream, transferring the resident to a wheelchair, floating the heels, oral hygiene after meals, use of a foot brace, monitoring an ingrown toenail, and use of a PRAFO device. When questioned, a licensed nurse confirmed that the documentation was missing and could not verify whether the tasks had been completed as ordered. Additionally, there was inaccurate documentation regarding the provision of oral hygiene. The resident reported not receiving oral care, and a CNA confirmed during an interview that oral care supplies had not been set up and that she had not provided oral care, despite having documented that it was done. The DON verified these findings, indicating that the resident's clinical record did not provide a concise and accurate account of the care and treatments provided, as required by facility policy.
Failure to Follow Infection Control Practices in Shower Room
Penalty
Summary
The facility failed to implement appropriate infection control practices as required by its Infection Prevention and Control Program. During an observation in a shower room, a used glove was found on the sink and on top of the toilet tank, and the Account Manager confirmed that the glove should have been properly disposed of. In a separate observation in the same shower room, a soiled towel with visible stains was found on the floor, and the Account Manager acknowledged that the towel should have been placed in the dirty linen barrel. The Director of Nursing (DON) was informed of these findings and stated that the cleaning process for shower rooms should ensure they are free of used gloves and washcloths.
Failure to Clean and Disinfect Shower Rooms
Penalty
Summary
The facility failed to ensure that three shower rooms were properly cleaned and disinfected, specifically neglecting to clean the shower heads. During an interview, a resident reported that the showers appeared to have fecal matter present. Observations confirmed the presence of dark brown residue on the lower half of the shower heads and brown stains on the walls and shower head holders in the shower stalls. The Account Manager acknowledged that the shower heads had a constant leak and required replacement, and both the Administrator and DON confirmed the discoloration and residue observed during the inspection. Medical record review indicated that the resident who reported the issue had been admitted to the facility prior to the observation, but no additional medical history or condition at the time of the deficiency was provided.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement infection control practices as outlined in their own policies and procedures for a resident requiring Enhanced Barrier Precautions (EBP) during wound care. During an observed wound care treatment, an LVN and a CNA did not don gowns as required, despite an EBP sign posted outside the resident's room and a physician's order specifying the use of gown and gloves for direct care. The LVN prepared wound care supplies and the CNA assisted in turning the resident, both wearing gloves but not gowns. The LVN proceeded with the wound care treatment without a gown, stating that a gown was not necessary if the wound was not draining. However, the facility's policy and the EBP sign indicated that gowns and gloves were required for high-contact care activities, including wound care, regardless of wound drainage status. The resident involved was non-verbal, lacked decision-making capacity, and had a chronic wound in the sacrococcyx area. Medical records confirmed the need for EBP, and staff interviews later acknowledged that proper PPE, including gowns, should have been used during the wound care procedure. The Infection Preventionist and Director of Nursing both confirmed that the observed practice did not align with facility policy and recognized the potential for infection transmission when proper PPE is not utilized.
Failure to Lock Bed Wheels for Dependent Residents
Penalty
Summary
The facility failed to maintain a safe environment for three nonsampled residents by not ensuring that bed wheels were locked while the residents were in bed. Observations confirmed that Residents A, B, and C were each found lying in beds with unlocked wheels. Staff members, including a CNA and an LVN, verified during interviews that the bed wheels were indeed unlocked at the time of observation. Medical record reviews for these residents indicated that all three had significant care needs, including dependence on staff for bed mobility, transfers, and activities of daily living, as well as documented risks for falls. Resident A had a diagnosis of unspecified dementia with psychotic disturbance and was care planned for self-care deficits and fall risk. Resident B had diagnoses including obesity, difficulty walking, hemiplegia, and hemiparesis, and used a trapeze bar for mobility; this resident also had a recent assisted fall and was care planned for fall risk and substantial assistance with mobility. Resident C had dementia, bowel incontinence related to immobility, and was dependent on staff for transfers and hygiene, with a care plan noting fall risk. Staff interviews confirmed that the facility's process for resident safety included locking bed wheels, but this was not followed for these residents.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A deficiency was identified when a cognitively intact resident, as indicated by a BIMS score of 15, was not treated with dignity and respect by a CNA. The resident was observed sitting in his wheelchair at his doorway, repeatedly calling the CNA by name. The CNA initially ignored the resident and, when she did respond, replied with a curt 'what' rather than addressing the resident respectfully. The resident expressed dissatisfaction with the interaction, stating he had been waiting for 30 minutes and felt as though he was working for the CNA. Interviews with other staff, including another CNA, an RN, and the DON, confirmed that responding to residents with 'what' is not considered respectful or acceptable according to facility policy. The facility's policy on promoting and maintaining resident dignity requires staff to speak respectfully to residents. The incident was acknowledged by facility leadership after being brought to their attention.
Failure to Follow Resident Food Preferences
Penalty
Summary
The facility failed to follow a resident's documented food preferences as outlined in their policies and procedures. During a meal observation, it was noted that a cognitively intact resident did not receive whole milk with their lunch, despite it being listed on their meal ticket. A CNA confirmed that the whole milk was missing and stated that she also had to retrieve whole milk for the resident at breakfast. The Dietary Services Supervisor (DSS) verified that all items on the meal ticket, including whole milk, should have been served. The Administrator and Director of Nursing (DON) were made aware of these findings and acknowledged the issue. The deficiency was identified through observation, interviews, and review of facility documentation, which showed that the resident's nutritional preferences were not consistently honored as required by facility policy.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician of a change in a resident's condition, specifically regarding the refusal of bowel management medications over a three-day period. The resident, who had been refusing stool softeners and other bowel management medications from January 1 to January 3, did not have a bowel movement during this time. Despite the facility's policy requiring notification of a physician when there is a change in a resident's condition, there was no documented evidence that the physician was informed of the resident's medication refusal. On January 4, the resident finally had a bowel movement, but later complained of severe pain and requested to go to the hospital. The resident was subsequently transferred to the hospital, where a CT scan revealed diverticulitis with an abscess and an associated ileus or possible small bowel obstruction. The Director of Nursing acknowledged that the physician should have been notified of the resident's refusal to take bowel management medications.
Failure to Update Elopement Risk Assessments
Penalty
Summary
The facility failed to ensure the necessary care and services to prevent elopement for two residents. Resident 2, who was admitted with dementia and a low risk for elopement, exhibited increased wandering behaviors shortly after admission. Despite these changes, the facility did not update Resident 2's elopement risk assessment when a Wander Guard was placed on the resident's wrist. The Director of Nursing (DON) confirmed that a new elopement risk evaluation should have been completed following the change in Resident 2's behavior. Resident 4, also diagnosed with dementia, was not assessed for elopement risk quarterly as required by the facility's policy. Although Resident 4 had an elopement attempt and was seen outside the facility, the elopement risk assessments were not completed at the necessary intervals. The DON verified that the assessments were only completed upon admission and after an elopement attempt, missing several required quarterly assessments. This oversight failed to capture changes in Resident 4's elopement risk and the need for interventions.
Failure to Honor Resident's Medication Schedule Request
Penalty
Summary
The facility failed to respect a resident's right to self-determination by not administering medications according to the resident and family member's request. Resident 1, who was initially admitted to the facility, had their medication administration times altered without documented justification after returning from a hospital stay. The facility's policy on resident rights emphasizes supporting residents' choices, including medication schedules. However, upon Resident 1's return from the hospital, the administration times for cholecalciferol and cyanocobalamin were changed from 1300 hours to 0900 hours, contrary to the previously agreed schedule. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN 3) revealed that the medication schedule was initially adjusted to spread out administration times per the resident and family's request. However, upon readmission, the facility failed to resume the agreed-upon schedule. Family Member 1 attempted to discuss the medication schedule with the facility before Resident 1's readmission but was unable to do so. Consequently, the medications were administered at 0900 hours, including additional medications, without adhering to the previously established schedule, leading to a failure in honoring the resident's rights.
Failure to Provide Timely Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a potential risk of catheter-associated urinary tract infections. The resident, who had moderate cognitive impairment, had an indwelling urinary catheter inserted due to urinary retention. However, the facility did not provide the necessary daily catheter care until five days after the insertion. This lapse in care was confirmed through interviews with the resident, a family member, and a Licensed Vocational Nurse (LVN), who acknowledged that catheter care was not ordered or rendered until several days after the catheter was inserted. The facility's policy and procedure for urinary catheters required continual assessment and proper handling of catheters, including keeping the urine collection bag below the bladder level and ensuring the catheter tubing was unobstructed. Despite these guidelines, the resident's catheter site was not checked or cleaned, and a bruise was observed by a family member during a urologist appointment. The Director of Nursing (DON) confirmed that catheter care should have been ordered upon insertion and that nurses were expected to assess the catheter site for signs of infection. The failure to adhere to these standards posed a risk for the resident to develop catheter-associated urinary tract infections.
Failure to Withhold Medication Despite Loose Bowel Movements
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a resident was administered docusate sodium, a stool softener, despite having loose bowel movements or diarrhea, which was against the physician's order to hold the medication under such conditions. The resident had a history of fluctuating capacity to understand and make decisions, with a BIMS score indicating moderate cognitive impairment. The physician's order clearly stated to administer the medication twice daily unless the resident experienced loose bowel movements. The medication administration records showed that the resident received the medication on multiple occasions when they had loose stools, as documented in the bowel elimination records. An LVN confirmed administering the medication without being informed of the resident's bowel condition, and the DON verified the discrepancy between the medication administration and the resident's bowel movement records. This oversight in communication and adherence to physician orders led to the administration of unnecessary medication to the resident.
Failure to Accommodate Resident's Bathing Request
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident who requested a bath on a specific date. The resident, who had a moderate cognitive impairment with a BIMS score of 12, expressed frustration when his request for a bath was not fulfilled. The resident had returned from the hospital the day before and refused a scheduled shower, opting instead to request a bath the following day. However, the bath was not provided until the day after the request, as the CNA assigned to the resident was working a double shift and needed to take a break. Interviews with the resident, family member, and facility staff, including the DSD and LVN, confirmed that the bath was not documented as given on the requested date. The DSD and DON verified that the facility's records did not show a bath being provided on the requested date, and the LVN could not recall if the bath was given or who was responsible for it. This oversight led to the resident feeling frustrated, which could negatively impact their physical and emotional well-being.
Failure to Update Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop a comprehensive care plan to address a change in condition for one of the sampled residents. On 11/11/24, the resident exhibited mild weakness and a flushed face, but the care plan did not reflect this change in condition. The resident's medical history included fluctuating capacity to understand and make decisions, with a BIMS score indicating moderate cognitive impairment. Despite these observations, the care plan was not updated to address the resident's new symptoms, as confirmed by interviews with LVN 2 and RN 1. The Director of Nursing was informed and acknowledged the findings.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to ensure the accurate administration of medications for a resident, specifically regarding the administration of psyllium, a soluble fiber used as a bulk-forming laxative. The physician's order required the administration of one capsule by mouth twice a day. However, due to a pharmacy error, the resident received an extra capsule on multiple occasions. This discrepancy was noted in the resident's progress notes, which indicated that the pharmacy delivered a wrong medication bubble pack containing two psyllium capsules. The resident, who had a fluctuating capacity to understand and make decisions and a BIMS score indicating moderate cognitive impairment, received an extra capsule of psyllium on four separate days. The Director of Nursing (DON) confirmed this error during an interview and medical record review. The failure to administer the medication as ordered by the physician had the potential to negatively affect the resident's well-being.
Inaccurate Documentation of Bladder Elimination for Residents with Catheters
Penalty
Summary
The facility failed to ensure the accuracy of medical records for three residents who had indwelling urinary catheters. The Certified Nursing Assistants (CNAs) inaccurately documented these residents as incontinent in the Task-Bladder Elimination records, despite the presence of the catheters. This discrepancy was identified through interviews, medical record reviews, and facility policy and procedure reviews. The inaccurate documentation had the potential to impact the residents' care needs due to the incorrect medical information. Resident 1, who had fluctuating capacity to understand and make decisions, was documented as incontinent on two occasions while having an indwelling urinary catheter. Resident 2, who had the capacity to understand and make decisions, was documented as incontinent on multiple occasions over a span of several weeks, despite having a catheter. Similarly, Resident 3, who also had an indwelling urinary catheter, was inaccurately documented as incontinent on numerous occasions. The Director of Nursing (DON) confirmed the inaccuracies in the documentation during an interview and concurrent medical record review.
Failure to Notify Physician and Apply Splints as Ordered
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. For Resident 1, the facility did not notify the physician when the resident had no bowel movements for more than three days, despite having a bowel management protocol in place. The resident was on a bowel management medication regimen, but the lack of bowel movement from 9/29/24 to 10/3/24 was not communicated to the physician, which was against the facility's policy. This oversight was confirmed by both the LVN and the DON during interviews. For Resident 2, the facility did not adhere to the physician's orders regarding the application of dynamic splints. The resident, who had diagnoses including Parkinson's Disease and contractures, was ordered to have dynamic splints applied three times a day. However, the splint tracking log and progress notes revealed multiple instances where the splints were not applied as ordered. Interviews with the PT and LVN confirmed that the splints were crucial for the resident's functional improvement, yet there was no documentation of refusals or education provided to the resident about the benefits of the splints. These failures in following physician orders and facility protocols had the potential to negatively impact the residents' well-being. The facility's policies on constipation management and the use of assistive devices were not followed, leading to a lack of necessary care for the residents involved.
Failure to Provide Correct Oral Hygiene Tools
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 2's oral hygiene needs, as observed during a survey. Resident 2, who was admitted and readmitted to the facility on unspecified dates, was found using an incorrect dental tool for brushing their teeth. During an observation and interview, it was noted that Resident 2 used a short handle brush with bristles on both sides, typically used for cleaning dentures, instead of a regular toothbrush. This occurred because CNA 2 did not provide the regular toothbrush, which Resident 2 preferred and was supposed to use for brushing their teeth. Further interviews with LVN 4 and the DON confirmed that the short handle brush was intended for denture cleaning, while the regular toothbrush was meant for Resident 2's teeth. LVN 4 acknowledged Resident 2's preference for the regular toothbrush, and the DON verified the intended use of both brushes. This oversight in providing the correct toothbrush potentially impacted Resident 2's well-being, as the facility's policy requires accommodations to meet individual needs and preferences.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to sanitary requirements in the kitchen, as observed during a survey. Dietary and non-dietary staff were found not wearing hair restraints, which is a violation of the Food Code of 2022. This was confirmed during observations and interviews with staff members, including a Dining Assistant and the Dietary Services Supervisor (DSS). The DSS acknowledged that kitchen staff should wear hair restraints for any exposed hair, beard, and body hairs. Additionally, the facility did not ensure proper labeling and dating of food items in the kitchen. During an initial tour, several food containers were found without labels or dates, including an opened container of Montreal chicken seasoning and clear containers of red and brown powders. This was verified by a cook present during the observation. Furthermore, kitchen equipment and utensils were not maintained in a sanitary condition. The microwave had food debris and rust, and a corroded pan was found among other pots and pans. Plates ready for use were also observed with food debris. The facility also failed to maintain sanitary conditions for cutting boards and air-drying of utensils. Cutting boards were heavily marred and discolored, making them difficult to clean and sanitize. Plates and insulated domes were observed wet, indicating they were not air-dried properly. Lastly, a scoop was improperly stored inside a bin containing oatmeal, contrary to the facility's policy on food storage. These deficiencies had the potential to cause foodborne illnesses among the residents consuming food prepared in the kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several deficiencies observed during the survey. The facility did not have documentation of a Legionella risk assessment, control measures, or testing protocols, which are essential to prevent the growth and spread of Legionella and other opportunistic pathogens in the water system. The Maintenance Supervisor confirmed the absence of these critical documents and acknowledged the lack of records for using chlorine tablets in decorative water fountains. Additionally, CNAs 11 and 12 did not adhere to Enhanced Barrier Precautions (EBP) when providing care to Resident 34, who had a Foley catheter and was under EBP. They failed to wear gowns and perform hand hygiene before donning gloves, which are necessary steps to prevent the transmission of multidrug-resistant organisms. The Director of Nursing (DON) confirmed that repositioning a resident is considered high-contact care, requiring full PPE, including gowns. The facility also failed to ensure that employee personal items were not stored in the clean laundry area, as observed with personal items placed on a table where linens were being folded. Furthermore, visitors in Resident 109's room did not follow contact isolation precautions, as they were not wearing PPE despite the resident being on contact isolation for ESBL in urine. Lastly, CNA 14 did not change gowns between assisting two residents, which is a breach of standard precautions to prevent cross-contamination.
Failure to Obtain and Document Advance Directives
Penalty
Summary
The facility failed to ensure that copies of advance directives were obtained or that information on how to formulate an advance directive was provided for eight of the 24 sampled residents. This deficiency was identified through interviews, medical record reviews, and facility policy and procedure reviews. The facility's policy requires informing and providing information to all new residents upon admission regarding their rights to accept or refuse medical treatment and to formulate an advance directive. However, the facility did not adhere to this policy for several residents. For Resident 34, there was no documented evidence that the resident was offered information on how to formulate an advance directive, despite having the capacity to understand and make decisions. Similarly, Resident 81's medical record showed no attempt to obtain a copy of the resident's advance directive, even though the resident had one. Resident 566, who had cognitive and psychiatric impairments, also lacked documentation of an attempt to obtain an advance directive. Other residents, such as Resident 59, had incomplete advance directives that were not verified for completeness before being uploaded into the electronic health record. Resident 75 was not provided with written information regarding advance directives, and Resident 89's POA was for financial authority rather than healthcare, with no attempt made to obtain an advance directive for healthcare. Additionally, Residents 109 and 414 had no documented evidence of attempts to obtain their advance directives, despite having the capacity to understand and make decisions.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which resulted in deficiencies in addressing their individual care needs. Resident 20, who had severe cognitive impairment, experienced a fall on 9/15/24, but no care plan was developed to address this incident. During an observation and interview, it was confirmed by LVN 1 and RN 1 that there was no care plan in place for the fall, despite the presence of bilateral floor mats in the resident's room. Similarly, Resident 42, who lacked the capacity to make decisions, was prescribed sertraline for depression, but the facility did not create a care plan to manage the use of this antidepressant medication. This was verified by LVN 3 and acknowledged by the DON. Additionally, Resident 81, who had intact cognition, was prescribed Keflex for an infected wound, yet no care plan was developed to address the use of this antibiotic. LVN 13 confirmed the absence of a care plan, and both the Administrator and DON acknowledged these findings.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as evidenced by the lack of proper labeling, dating, and storage of respiratory equipment. For Resident 814, the oxygen nasal cannula tubing, humidifier, and Yankauer were not dated or labeled, and were not stored in a set-up bag when not in use. Additionally, there was no care plan developed for the resident's oxygen use and monitoring, nor was there a physician's order for oral suction at the bedside. This oversight was confirmed by LVN 3 and RN 1, who acknowledged the absence of necessary documentation and care plans. Similarly, Resident 76's oxygen tubing, humidifier, and storage bags for the nebulizer and suction devices were not dated or labeled, and there was no set-up bag for the oxygen tubing. LVN 17 verified these findings and stated that the respiratory devices and storage bags should be dated, labeled, and changed weekly. Resident 564 also had a storage bag for the nebulizer that was not dated or labeled, as confirmed by LVN 2, who emphasized the importance of changing respiratory supplies weekly for infection control. Other residents, including Residents 10, 42, 87, 75, 89, 414, 417, and 418, were found to have similar deficiencies in the management of their respiratory equipment. The nasal cannulas, humidifiers, and set-up bags were either undated, unlabeled, or not changed weekly as required. These findings were verified by various staff members, including LVNs and the Central Supply Clerk, who confirmed the facility's policy for changing and labeling respiratory equipment. The DON acknowledged these deficiencies, highlighting a systemic issue in the facility's respiratory care practices.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 5,879 citations issued within 25 miles in the last 12 months — including the 24 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Alamitos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seal Beach Health And Rehabilitation Center | 3 mi | ★★★★★ | 2 | 0 |
| Park Anaheim Healthcare Center | 3.6 mi | ★★★★★ | 28 | 0 |
| Anaheim Point | 3.6 mi | ★★★★★ | 0 | 0 |
| Anaheim Terrace Care Center | 3.9 mi | ★★★★★ | 2 | 0 |
| Healthcare Center Of Orange County | 4.2 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.