Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Anaheim Crest Nursing Center during CMS and state inspections, most recent first.
Residents were recorded during an entertainment event and the video was later posted on social media without proper consent for all involved. The Administrator said an entertainer used a cellphone to record the event and the DON acknowledged the social media consent was not completed for one resident. A resident and a responsible party reported feeling humiliated and embarrassed after the posting.
Psychotropic medication monitoring and documentation were incomplete and inaccurate for several residents. A resident receiving mirtazapine had meal intake records that did not match CNA documentation, inaccurate side effect coding, and no documented nonpharmacological interventions before administration. Other residents receiving bupropion, sertraline, trazodone, Seroquel, and duloxetine had missing or combined documentation for behaviors, side effects, sleep monitoring, and nonpharmacological interventions, with staff acknowledging the records did not clearly show the required monitoring for each medication.
The facility failed to follow its abuse prevention and consent protocols when an entertainer recorded residents during an event and the video was later posted on social media. A resident with decision-making capacity, another resident, and a nonsampled resident were included in the recording without proper social media consent, and interviews showed the facility did not have a file for the entertainer or complete background check and abuse-prevention in-services. The residents and a responsible party reported humiliation after the post appeared online.
Failure to Develop and Implement Individualized Care Plans: The facility did not ensure individualized care plans were developed or implemented for several residents with specific needs. A resident with prurigo nodularis had no care plan for the new skin condition, another resident using CPAP at the bedside had no related care plan, and a resident using a Dexcom G7 had no care plan for the blood sugar monitoring device. For a resident with CKD, hydronephrosis, urinary retention, and a chronic Foley catheter, urinary output was not documented as required and bilateral floor mats listed in the falls care plan were not observed at the bedside.
The facility failed to follow ordered skin treatments for a resident with prurigo nodularis, including using the correct therapeutic shampoo strength and updating care after a dermatology diagnosis. It also failed to rotate insulin injection sites for two residents as ordered, with repeated use of the same arm or abdominal site, and failed to obtain/document an order and care instructions for a resident’s Dexcom G7 CGM and probe site care. Staff and the DON verified several of the findings.
GT supplies were not properly labeled for three residents receiving enteral feeding and free water via pump. Free water bags were observed hanging without the resident’s name, date, time, or other required labeling, and a piston irrigation syringe was also observed without documentation of when it was changed. An LPN and the DON acknowledged the missing labels during observation and interview.
Respiratory care was not provided as ordered for several residents. A resident was observed receiving oxygen at rates different from the physician order and had an unlabeled nasal cannula and dated storage bag. Other residents had unlabeled or undated oxygen tubing, masks, or cannulas, equipment left exposed to air or not stored in a bag, and one resident’s CPAP mask and tubing lacked a physician order for care and maintenance. One resident was also observed with an oxygen humidifier that was not current, and another had nebulizer equipment left unlabeled and unsecured.
Expired and improperly labeled food was found in kitchen refrigeration areas. Surveyors observed sauerkraut past its use-by date, multiple vegetables and parsley with expired dates, and several opened items including soy bean paste, hot pepper paste, bread, and green cabbages without required dates or labels. The DSS verified the findings.
Incomplete and inaccurate medical record documentation affected multiple residents. A resident’s code status was not reflected in the EMR, another resident had conflicting trazodone consent dosages, several residents had incomplete POLST advance directive sections, one resident’s edema documentation did not match between the treatment record and weekly nursing notes, and another resident’s post-fall record was created for an incident staff later said did not occur. These record errors involved RN, LVN, SSD, and DON documentation and left the chart inconsistent with the residents’ actual status and events.
Infection control surveillance was incomplete because the IP only tracked residents with antimicrobial use or diagnosed infections, while residents with signs and symptoms of infection but no antibiotics were not included in the log or monthly report. The water management plan also lacked a Legionella testing intervention for a water main break. Surveyors observed an RN leaving a room with gloves on after med pass, a CNA returning a call light from the floor without sanitizing it, a resident handling clean clothing in an open storage closet, and two residents with thickened water pitchers that had not been changed daily.
Incomplete informed consent for psychotropic medications: Two residents had psychotropic medication consents that were missing required information. One resident’s mirtazapine consent did not document nonpharmacologic approaches or the prescriber’s e-signature. Another resident’s alprazolam, bupropion, and sertraline consents did not identify whether the drugs were off-label, FDA-approved, or had a boxed warning, and the alprazolam consent also lacked the prescriber’s e-signature. RN verified the omissions during record review, and the DON was informed.
A resident had Zoryve Cream 0.3% at bedside and stated she applied it herself daily, but there was no MD order allowing self-administration or keeping the medication at bedside. The chart showed an order for the cream to be applied topically once daily, noted that the family was to provide the medication, and contained no IDT assessment for self-administration; an LVN confirmed the cream should not have been at bedside.
Advance Directive Not Maintained in Resident Record: A resident who could make needs known but could not make medical decisions had an advance directive noted in the social service record, yet the document was not found in the chart. The SSD confirmed the resident had an advance directive but could not locate a copy, and there was no documented follow-up with the resident or family representative to obtain it.
A resident with paraplegia and intact cognition used a transfer pole in bed for turning and during care, but the OT/PT evals and later rehab screen did not document the pole’s use, benefit, clinical justification, or appropriateness. The care plan identified the transfer pole, yet the restorative nursing order focused only on lower-extremity PROM, and the DOR, MDS Coordinator, and DON acknowledged the missing assessment and documentation.
Failure to provide an ordered low air loss mattress for a resident with a sacral pressure injury was identified during observation, interview, and MR review. The resident had an unstageable sacral PI that later progressed to a stage 3 PI, and the physician ordered a low air loss mattress for wound management. Staff verified the mattress was not in use when the resident was observed in bed, despite the facility’s support surface guidance for residents at risk for skin breakdown.
The facility failed to complete ordered post-fall neuro checks for a resident with severe cognitive impairment after an unwitnessed fall with a lip abrasion and bleeding. The facility also failed to follow its smoking policy for a resident who required supervision to smoke, as staff observed the resident keeping cigarettes in his shirt pocket even though only independent smokers were allowed to keep smoking materials in their possession.
Failure to Obtain Ordered Weekly Weights: A resident with significant recent weight loss had an IDT plan and MD order for weekly weights, but the facility did not obtain the ordered weekly weight for the following week. The DSD and DON verified the last recorded weight was before the ordered weekly monitoring period, despite the resident’s documented 12 lb. loss and ongoing weight management interventions.
Failure to Document Baseline Midline IV Measurements: A resident receiving IV antibiotics via a midline IV had no documented baseline external catheter length or arm circumference measurements when admitted from the acute hospital. The resident’s care plan did not address the midline IV, and the IV MAR lacked baseline documentation. RN confirmed staff performed dressing changes and measurements, but could not verify any baseline values from the acute care hospital; the DON verified the findings.
A resident with sciatica and fibromyalgia had pain management failures involving a prescribed lidocaine patch and PRN hydrocodone-acetaminophen. The patch was not given as ordered because it was not available from pharmacy, and the record did not show documented nonpharmacological interventions before opioid administration or monitoring of opioid side effects as outlined in the care plan.
Inaccurate dialysis access documentation was found for a resident receiving hemodialysis three times weekly through a right upper chest Permacath. The Dialysis Communication Record repeatedly showed bruit and thrill as present on pre- and post-dialysis assessments, even though staff and the DON confirmed a Permacath does not have bruit and thrill. Staff also described the access inconsistently, including references to an AV shunt, while the resident’s orders required monitoring the site each shift for tenderness, redness, and bleeding.
The facility failed to ensure RN competency in assessing a resident’s Permacath dialysis access and failed to ensure an LVN demonstrated competency in administering eye drops and nasal spray. RN 1 and RN 2 described monitoring the access for bruit and thrill, while the DON stated those assessments would not apply to a Permacath. For another resident, an LVN administered artificial tears to both eyes and fluticasone nasal spray, but did not ask the resident to blow his nose first, and the annual skills checklist did not include nasal spray administration.
The facility failed to ensure accurate med administration and controlled drug reconciliation. An LPN administering GT meds used cold water and the wrong Pro-Stat product instead of the ordered sugar-free supplement, another LPN gave nasal spray without having the resident blow his nose first, hydrocodone-acetaminophen was removed from the narcotic drawer without MAR documentation of administration, and multiple controlled med count entries were missing the required two-nurse signatures.
Failure to Document Monitoring for Eliquis Side Effects: A resident with atrial fibrillation had an order for Eliquis 5 mg BID and a care plan that included monitoring for bruising and bleeding. However, the medical record did not show documented monitoring for anticoagulant side effects, and an LVN confirmed there was no evidence the resident was monitored for bleeding or bruising.
Medication administration errors exceeded the allowed rate, with an observed error rate of 7.69%. An LPN gave sodium chloride to a resident without meals even though it was ordered with meals, and gave another resident the wrong artificial tears formulation instead of the ordered ophthalmic solution. The DON was informed and acknowledged the findings.
Medication Room A was observed left open with a trash can propping the door, and staff confirmed it should have remained locked. Internal and external meds were stored together on a lower shelf, including calcium carbonate, diclofenac sodium gel, budesonide/formoterol, mineral oil enema, and saline laxative enema. The Drug Destruction Log also showed multiple entries signed by only one nurse, with one undated entry lacking the required two nurse signatures.
A resident ordered a chopped meat diet was served meat that appeared ground rather than chopped during meal observations. The CNA stated this was what the resident ate all the time, and facility staff acknowledged the meal had a ground-like appearance while saying the mechanical soft recipe had been followed. The dietitian stated the preparation was inaccurate for a chopped meat order, and the DON acknowledged the meat did not appear chopped.
Blood glucose meter QC was not documented for one of two Assure Platinum meters on Medication Cart A, even though either meter was used for resident blood sugar checks and one meter had been broken for a week. In addition, both medication refrigerators in Medication Room A were observed with ice buildup in the freezer compartments, and the LVN confirmed the condition.
The facility failed to protect resident privacy when an outside performer recorded residents during an activity and posted the videos on social media without appropriate consent. One resident with severe cognitive impairment had a consent form allowing photography only for a facesheet, and the responsible party stated no permission was given for videos or social media posting, noting that the online content included humiliating comments. Another cognitively intact resident had consented only to photography for a facesheet, dietary card, and medication records, and reported seeing the performer record residents with a personal phone without expecting the footage to be uploaded. The Admissions Coordinator and Administrator confirmed that neither resident’s consent authorized social media use, and the Administrator acknowledged allowing the performer to record the event without checking residents’ consents or imposing restrictions.
The facility failed to ensure that written transfer/discharge notices, including bed-hold and return policies, were provided directly to residents and/or their representatives when three residents were transferred to an acute care hospital. In multiple cases, staff documented that notices were "provided" but recorded the method as sending the forms with transfer paperwork to the hospital via paramedics, rather than giving them to the resident or responsible party. For one resident with severe cognitive impairment and another with a sudden change in mental status, the notices were completed by nursing staff but routed with hospital transfer documents instead of being clearly delivered to the responsible party. For a third resident with moderate cognitive impairment, the section indicating that a written copy was provided was left blank, while the method again showed it was sent with transfer paperwork. During interviews, the DON and nursing staff described a routine practice of verbally informing residents/families and placing the notice forms in an envelope for the hospital, with no consistent documentation that the written notices were actually given to the residents or their representatives.
A resident with moderate cognitive impairment alleged that an LVN engaged in inappropriate physical contact. The incident was reported to a CNA, who informed the LVN, but the LVN did not escalate the allegation to a supervisor. The facility delayed reporting the abuse allegation to the state agency, contrary to its policy requiring immediate notification.
Surveyors found that kitchen utensils and equipment were not properly cleaned, maintained, or air dried, with multiple items observed to have residue, watermarks, and fuzzy films. Some utensils were damaged or worn out, and the kitchen hood was found with greasy residue. These deficiencies were acknowledged by the DSS and affected the majority of residents consuming food prepared in the kitchen.
A resident was found with a topical pain medication left at the bedside for self-application without a physician's order, assessment, or care plan authorizing self-administration. Nursing staff confirmed that medications should not be left at the bedside, and the DON verified that required documentation and orders were missing.
Two residents were found without accessible call lights, despite care plans and facility policy requiring call lights to be within reach. One resident with decision-making capacity had the call light on the floor and could not locate it, while another resident with severe cognitive impairment had the call light clipped to the wall and was unable to use it. Both situations were confirmed by an LVN and the DON.
Two residents did not have comprehensive, individualized care plans reflecting all required interventions. For one, the care plan for mood and behavioral symptoms omitted non-pharmacological interventions listed in the psychoactive medication consent. For the other, the care plan did not address PASARR Level II recommendations, despite a history of mental health conditions. Staff confirmed these omissions during interviews and record reviews.
Surveyors found expired biohazard spill kits on a crash cart and observed hydrocortisone cream stored unlocked and mixed with food thickener and other items on a medication cart. The MDS Coordinator confirmed these practices did not follow facility policy for secure and appropriate medication storage.
A resident's POLST form was inaccurately completed, indicating that an advance directive was not available, even though a Durable Power of Attorney had been uploaded into the electronic medical record. Facility staff confirmed the documentation should have reflected the presence and review of the advance directive, but this was not done.
The facility failed to ensure proper infection control practices, including not cleaning a call light after it was picked up from the floor and placed on a resident's bed, not communicating infection surveillance data for antibiotic stewardship to the physician when a resident was prescribed antibiotics without meeting infection criteria, and not screening pneumonia cases for possible Legionnaire's disease or coordinating water system testing as required by policy.
Dietary staff did not follow the prescribed portion size for pureed Mandarin Oranges, serving four ounces instead of the required three ounces as outlined in facility policy and recipes. The DSS confirmed that the correct scoop was not used, resulting in residents receiving a larger portion than planned.
The facility did not update care plans for two residents to reflect their current needs. One resident's care plan required monitoring the effectiveness of a skin treatment, but staff did not evaluate or document this as directed. Another resident's care plan included encouraging verbalization of feelings, even though the resident was unable to communicate due to cognitive decline. Staff confirmed these interventions were not appropriate or followed, and the care plans were not revised accordingly.
A resident with dysphagia and no decision-making capacity received enteral feeding, but the enteral water feeding bag was not changed within the required 24-hour period as per facility policy. This was confirmed by an LVN and acknowledged by the DON during the survey.
The facility did not ensure that daily nurse staffing information, detailing the total number and actual hours worked by licensed and unlicensed nursing staff per shift, was posted as required. During an observation and interview, an RN and an LVN were unable to locate the required posting and confirmed it was missing.
A resident receiving IV antibiotics for a venous ulcer/cellulitis had a peripheral IV site that was not labeled according to facility policy, missing the time of insertion, staff initials, and catheter details. Additionally, there was no documentation in the medical record to confirm that the IV site was changed as indicated on the label, and the DON confirmed this lack of documentation.
A resident with COPD was observed using a nasal cannula for oxygen therapy that was not labeled or dated as required by facility policy. An RN confirmed the omission, noting that labeling is necessary for staff to know when to change the cannula, and the DON verified the findings.
A resident was given a 50 mg tablet of zinc sulfate instead of the prescribed 220 mg by an LVN, despite clear physician orders and facility policy requiring accurate medication administration. The error was confirmed through record review and staff interviews, with the DON acknowledging the nurse did not verify the order or medication prior to administration.
Surveyors observed that both outside garbage dumpsters had lids that were not fully closed due to bulky boxes and trash bags, preventing proper containment of waste. The Maintenance Director confirmed that the lids should be closed for infection control, and facility policies require tightly closed, leakproof containers for waste disposal.
A facility failed to report an abuse allegation involving a resident to the CDPH, L&C Program in a timely manner, as required by its policy. The resident, who was cognitively intact, alleged abuse due to missed meals, unanswered call lights, and retaliation. The facility attempted to report the incident but mistakenly faxed the report to its own number instead of the correct CDPH, L&C Program's number.
The facility failed to meet food safety and sanitation standards, including improper monitoring of TCS foods, inadequate hand hygiene practices, and poor labeling and storage of food items. These deficiencies were confirmed by the DSS and had the potential to cause foodborne illnesses among residents.
The facility failed to ensure call lights and bed controls were within reach for two residents, potentially impacting their psychosocial well-being and delaying care. A resident's call light and bed remote were found out of reach, confirmed by an RN, while another resident's call light was observed on the floor, verified by an LVN and the DON.
A facility failed to notify a resident's representatives and the LTC Ombudsman in writing about the resident's transfer to an acute care hospital. The resident, who lacked decision-making capacity, was transferred twice without the required notifications. The facility's policy mandates written notification of transfer details and appeal rights, but the Medical Records Department did not send these notices.
A facility failed to provide a written bed hold policy to a resident's representative during hospital transfers, as required by their policies. The resident, who lacked decision-making capacity, was transferred twice without the representative receiving the necessary documentation. Interviews with staff confirmed the oversight, with the Medical Records Department unable to provide evidence of compliance.
Residents Recorded and Posted on Social Media Without Proper Consent
Penalty
Summary
The facility failed to ensure two sampled residents and one nonsampled resident were treated with respect and dignity when a video of them was posted on social media. The report states that Residents 3 and 6, along with Resident 56, were recorded during an entertainment event in the dining room, and the video later appeared on a social media platform. The deficiency was identified through observation, interview, medical record review, and review of facility policies and procedures. Resident 3 was admitted to the facility and had an H&P dated 3/10/26 showing capacity to understand and make decisions. The record included a consent for photographs form listing social media, brochure, and flyer use, but the form had no resident or representative signature or date. The Admissions Director stated Resident 3's responsible party signed consent only for the face sheet, dietary cards, and medical records, and did not consent to social media use. Resident 3's responsible party stated he did not sign any consent for Resident 3 to be photographed or posted on social media and said the posting caused humiliation and distress to the family. The Administrator stated an entertainer recorded the event with a cellphone and that she continued the recording when the entertainer had to perform. She also stated there was a possibility the video would be posted on social media. The DON stated the social media consent was not done for Resident 3 and that the resident should not have been in the video. Resident 6 stated she did not want her picture posted and felt humiliated when she learned it had been shared. Resident 56 stated he did not know the video would be posted, felt humiliated and embarrassed, and said he would not have attended the event if he had known it would be online.
Psychotropic medication monitoring and documentation failures
Penalty
Summary
The facility failed to ensure that psychotropic medications were monitored and documented as ordered for multiple residents, including monitoring of meal intake, behaviors, side effects, and nonpharmacological interventions. The report states that the facility did not ensure four of five sampled residents reviewed for unnecessary medications, and one of 20 sampled residents, were free from unnecessary psychotropic medications. The deficiencies involved mirtazapine, trazodone, sertraline, Seroquel, bupropion, and duloxetine, with the facility’s own policies requiring adequate monitoring for efficacy and adverse consequences and the use of nonpharmacological approaches unless contraindicated. For one resident receiving mirtazapine for depression manifested by poor oral intake, the MAR documentation of meal intake did not match CNA documentation when the resident ate less than 50% of meals. The resident’s record also did not show nonpharmacological interventions were provided before the medication was administered. In addition, the side effect monitoring entry in the MAR was inaccurate, showing chart codes indicating dialysis and hospitalization even though the record did not support that the resident was on dialysis or hospitalized on the referenced date. The monthly behavior summary also did not match the CNA documentation of meal intake below 50%. For another resident receiving bupropion and sertraline, the facility documented nonpharmacological interventions and side effect monitoring together rather than separately for each medication and behavior, and the RN stated this made it impossible to know which medication the interventions or side effects related to. For a resident receiving duloxetine, the record did not show nonpharmacological interventions were attempted before administration, and staff stated the medication was routine and did not require such interventions unless PRN. For a resident receiving sertraline, trazodone, and Seroquel, the record showed missing entries for sleep monitoring, behavior monitoring, side effect monitoring, and nonpharmacological interventions on some shifts, and the record did not show side effects of Seroquel were monitored. Another resident receiving mirtazapine had inaccurate meal intake monitoring in the MAR compared with CNA documentation, and the record did not show nonpharmacological interventions were attempted before administration.
Failure to Protect Residents From Unauthorized Social Media Video Recording
Penalty
Summary
The facility failed to ensure its abuse prevention policies and procedures were followed when two sampled residents and one nonsampled resident were included in a video that was later posted on social media. The facility’s Abuse Prevention Program stated residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that administration will protect residents from abuse by anyone and develop policies and procedures to prevent abuse, neglect, or mistreatment. The Compliance and Ethics Program also described objectives related to internal controls, responsible corporate conduct, and preventing unlawful and unethical behavior. Resident 3 was admitted to the facility and had an H&P dated 3/10/26 showing the resident had the capacity to understand and make decisions. During an event in the dining room, an entertainer used a cellphone to record residents while performing. The Administrator stated she believed all residents had signed photo consents except one resident who was not in the dining room, and that the entertainer continued recording with her cellphone while performing. The Administrator later learned the video had been uploaded to social media and asked the entertainer to remove it, but the entertainer refused and requested financial compensation in exchange for removing the post. Interviews showed the facility did not have a file folder or agreement for the entertainer, and the Activities Director stated background checks and abuse-prevention in-services were not being done. The Admissions Director stated Resident 3’s responsible party had only signed consent for the face sheet, dietary cards, and medical records, and had not consented to social media use. Resident 3’s responsible party stated he did not sign any consent for the resident to be photographed or posted on social media and said the family experienced humiliation. Resident 6 and Resident 56 both stated they were in the video, did not know it would be posted online, and felt humiliated after seeing it on social media.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to ensure the comprehensive care plan was developed and implemented to reflect the individual care needs of four residents. Facility policy stated that a comprehensive person-centered care plan with measurable objectives and timetables is to be developed and implemented for each resident. The deficiencies involved Resident 17, Resident 23, Resident 49, and Resident 68, and were identified through observation, interview, medical record review, and facility policy review. Resident 17 had a physician progress record and skin/wound note showing a diagnosis of prurigo nodularis with self-inflicted scratching and picking after a dermatology appointment, but the plan of care did not show a care plan problem developed for that diagnosis. Resident 23 was admitted with obstructive sleep apnea and used a CPAP machine at the bedside, but the plan of care did not show a care plan addressing the CPAP use. Resident 68 was admitted with diabetes mellitus and used a Dexcom G7 blood sugar monitoring device, but the plan of care did not show a care plan addressing the device. Resident 49 had diagnoses including chronic kidney disease, hydronephrosis, urinary retention, and use of a chronic indwelling Foley catheter. His care plan included monitoring for signs and symptoms of acute renal failure and a separate falls care plan calling for bilateral floor mats beside the bed. However, the record did not show documented evidence that urinary output was monitored, and observations on two occasions showed no floor mats at the bedside. Staff interviews confirmed the absence of a care plan for the CPAP and Dexcom device, and the DON was informed and acknowledged the findings.
Failure to follow ordered treatments, insulin site rotation, and CGM orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for four sampled residents. The report states that these failures affected Resident 17, Resident 8, Resident 37, and Resident 68, and that the residents did not attain and maintain their highest practicable physical well-being. The deficiencies involved wound and skin treatment management, insulin injection site rotation, and the use and care of a blood glucose monitoring device. For Resident 17, the medical record showed physician orders for therapeutic coal tar shampoo and multiple topical treatments for dermatologic rash/open lesions on the right lower extremity and right upper extremity, torso, and back, along with doxycycline for impetigo. After a dermatology visit, the resident was diagnosed with prurigo nodularis with self-inflicted scratching/picking. The record did not show that the resident’s treatments were updated to reflect the new diagnosis and instead continued to reflect treatment for a dermatological rash. During review of the treatment cart and records, the LVN and RN verified the diagnosis of prurigo nodularis but could not show documentation that the treatments were updated. The LVN also showed a therapeutic shampoo with 0.5% coal tar even though the order specified 3% coal tar. For Resident 8 and Resident 37, physician orders required insulin to be administered subcutaneously and for injection sites to be rotated. Review of the blood glucose monitoring and location of administration records showed repeated use of the same sites rather than rotation. Resident 8 received regular insulin multiple times in the left arm and later multiple times in the left lower abdominal quadrant. Resident 37 received Humulin-R and insulin glargine repeatedly in the left lower quadrant of the abdomen on several occasions. RN 1 verified the findings and stated the injection sites should have been rotated with each administration. The DON was informed and acknowledged the findings. For Resident 68, the resident had a Dexcom G7 blood sugar monitoring device observed at the bedside and stated that the nurses helped apply the dressing and that the device was used to show blood sugar results. The record contained an order for Lispro insulin by sliding scale, but it did not contain a physician’s order for use of the Dexcom device or documented care instructions for the probe site. Staff interviews confirmed that the resident had the device, that finger sticks were still being used and compared, and that there was no physician order for the Dexcom G7 or care of the skin where the probe was placed.
GT Supplies Were Not Properly Labeled
Penalty
Summary
The facility failed to ensure appropriate care and services for gastrostomy tube use for three sampled residents. For Resident 5, who was admitted and later readmitted to the facility and had physician orders for Diabetisource 1.2 at 65 mL per hour and enteral free water via pump at 55 mL per hour, the free water bag was observed hanging and connected to the enteral feeding without the resident’s name, date, or start time. A piston irrigation syringe in a plastic bag was also observed hung at the enteral pole without the resident’s name, date, or time documented when the syringe was changed. For Resident 11, who had physician orders for Diabetisource 1.2 at 75 mL per hour for 20 hours and enteral free water via pump at 60 mL per hour for 20 hours, the free water bag was observed hanging and connected to the enteral feeding without the resident’s name, date, or time the bag was hung. A piston irrigation syringe in a plastic bag was also observed hung at the enteral pole without the resident’s name, date, or time documented when the syringe was changed. For Resident 81, whose H&P stated the resident lacked decision-making capacity and who had an order for free water via enteral pump at 60 mL per hour for 20 hours, the free water bag was observed with no resident’s name, infusion rate, date, time, or nurse’s initials. During observations and interviews, LVNs verified the bags and syringe labeling were missing and stated the labels should have been present when the items were hung or changed. The DON acknowledged the findings.
Respiratory equipment and oxygen orders not followed
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician orders and facility policy for multiple residents receiving oxygen and other respiratory treatments. Resident 5 had an order for oxygen at 2 liters per minute via nasal cannula continuously, but was observed receiving oxygen at 1.5 liters per minute and later at 2.5 liters per minute. Resident 5’s nasal cannula was also observed without a label or date, and the plastic bag hanging on the oxygen concentrator was dated 5/10/26 rather than being current. Resident 35 had an order for oxygen at 3 liters per minute via nasal cannula continuously and for the nasal cannula to be changed weekly and labeled with name and date. The resident was observed receiving oxygen, but the nasal cannula was not labeled with a date, and the plastic bag hanging on the oxygen concentrator was dated 5/10/26. Resident 57 had an order for oxygen at 3 liters per minute via nasal cannula continuously and for the cannula to be changed weekly and labeled. The resident was observed receiving oxygen at 4 liters per minute, the cannula attached to the concentrator was not labeled, the cannula attached to the oxygen tank on the wheelchair was not labeled and was exposed to air, and there was no bag to store it when not in use. Resident 74 was observed receiving oxygen at rates between 3 and 3.5 liters per minute, then later at 2 liters per minute, while the record showed an order for oxygen at 4 liters per minute at the time of the later observation. The oxygen humidifier in use was dated 5/9/26, although the order required it to be changed weekly on Sundays and as needed. Resident 23 had an order for oxygen at 3 liters per minute via nasal cannula continuously and a CPAP order for nighttime use, but the oxygen tubing was unlabeled and undated, and the record did not show a physician order for the care and maintenance of the CPAP mask and tubing as described by the manufacturer. Resident 89 had nebulizer treatments ordered and was observed with an unlabeled nebulizer mask exposed to air and no bag for storage; the nasal cannula attached to an oxygen tank was also unlabeled and on the floor, and the record did not show a physician order for oxygen use.
Expired and Undated Food Found in Kitchen Storage
Penalty
Summary
Food safety was not followed in the facility’s kitchen when expired food was found stored in the refrigerator and walk-in refrigerator. During observation with the DSS, a clear plastic container of sauerkraut had a best if used by date of 5/17/26. On a later observation, carrots in a clear plastic bag were dated 4/15/26, one red cabbage was dated 4/22/26, another red cabbage was dated 5/12/26, and parsley in a clear plastic bag was dated 4/4/26. The DSS verified these items were expired. The facility also failed to ensure opened and stored food items were properly dated and labeled. Observations identified an opened container of soy bean paste and an opened container of hot pepper paste without a date opened or use-by date, two opened bags of white bread without a date opened or use-by date, and one opened bag of wheat bread without a date opened or use-by date. Four green cabbages in the walk-in refrigerator were not dated or labeled. The DSS verified these findings and stated the food should be properly dated with a use-by date and a date opened date.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for six sampled residents. The deficiencies involved inaccurate or incomplete documentation of advance directives, code status, medication consent, a fall-related record, and nursing documentation of edema. Facility policy required documentation in the medical record to be objective, complete, and accurate, and to reflect all services provided, progress toward care plan goals, and any changes in a resident’s condition. For Resident 2, the medical record contained conflicting trazodone consent documents showing different dosages than the physician order, and the electronic medical record did not reflect the resident’s DNR status even though the POLST indicated DNR/allow natural death. Resident 2’s H&P showed the resident had capacity to make his own medical decisions. For Residents 9 and 49, the POLST forms were not fully completed in Section D for the advance directive. Resident 49’s H&P showed capacity to make his own medical decisions, while Resident 9’s H&P showed no capacity to make his own medical decisions. For Resident 10, the POLST form was also incomplete in the advance directive section, despite the resident having a legally recognized decision maker and no capacity to understand and make decisions. Resident 7’s record did not match between the treatment record and the weekly nursing progress notes for left upper extremity edema. The treatment record showed 4+ edema over the review period, while the weekly notes documented none on several dates and 1+ on another date. Resident 13’s record contained an incomplete post-fall review for an incident dated 4/24/26, but later interviews and record review showed the resident did not actually have a fall. The DON stated the post-fall documentation was created in error and that the risk management documentation was not included in the medical record. The record also contained documentation of assessment, interventions, and IDT review for a fall that staff later stated did not occur.
Infection Control Program and Practices Not Maintained
Penalty
Summary
The facility failed to maintain an accurate infection control surveillance program from November 2025 through April 2026. The infection preventionist stated that surveillance was initiated when a resident was prescribed antimicrobial medications or diagnosed with an infection, and that McGeer’s Criteria was used to determine whether a resident had a true infection. However, the surveillance logs reviewed for those months showed only residents classified as having either a healthcare-associated infection or a community-acquired infection, and no residents were documented as not meeting McGeer’s Criteria. The infection preventionist acknowledged that residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications, and were not diagnosed with an infection, were not included in the surveillance process. The facility also failed to include in its water management program an intervention for testing Legionella in the event of a water main break from the municipal water source. The Legionella Water Management Program and Legionella Detection and Surveillance document stated the facility would establish an infection control program to prevent, detect, and control water-borne contaminants, including Legionella, but the plan did not document testing for Legionella after a water main break. The maintenance director stated that water would be tested right away in that situation, but acknowledged that this testing process was not included in the written plan. Additional infection control failures were observed in resident care and environmental practices. An RN was observed leaving a resident’s room and walking in the hallway with gloves still on after medication administration without removing the gloves or performing hand hygiene. A CNA picked up Resident 73’s call light from the floor and returned it to the resident without cleaning or sanitizing it. Clean personal clothing stored in a closet was observed being handled by Resident 59, and staff confirmed the closet was used for residents’ clean clothing and should have been locked. In addition, thickened water pitchers for two residents were observed dated 5/15/26 and were not changed daily as expected; the DON acknowledged they had not been changed for three days. One resident had short- and long-term memory problems with severely impaired decision-making, and another resident had no capacity to understand and make decisions and was on a pureed diet with moderately thick liquids.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure that two sampled residents were fully informed and had proper informed consent documentation for psychotropic medications and related treatments. The record review and interviews showed that the facility’s Psychotropic Medication Use/Informed Consent policy required written informed consent with required signatures before psychotherapeutic drugs were prescribed or initiated, and the facility also reviewed state guidance describing required material information such as nonpharmacologic approaches, boxed warnings, and FDA precautions. For Resident 83, the physician ordered mirtazapine 7.5 mg, two tablets at bedtime for depression with poor oral intake. The informed consent form for the mirtazapine did not show that non-pharmacological approaches had been attempted, and the form did not contain the prescribing physician’s e-signature. The resident’s MAR showed the medication was administered from 4/1/26 through 5/19/26. During the concurrent review, RN 1 verified that the form did not identify the non-pharmacological approaches used and did not include the physician’s e-signature. For Resident 8, the physician ordered bupropion 150 mg daily for depression, alprazolam 2 mg twice daily for anxiety, sertraline 50 mg daily for depression, and later alprazolam 3 mg twice daily for anxiety. The informed consent forms for alprazolam, bupropion, and sertraline did not show whether the medications were off-label use, FDA-approved use, or had a black box warning label in the caution and warning summary section. The alprazolam consent form also did not include the prescribing physician’s e-signature. RN 1 verified these omissions during the medical record review, and the DON was informed of the findings.
Medication at Bedside Without Self-Administration Order
Penalty
Summary
The facility failed to ensure medications were safely administered for one resident who had Zoryve Cream 0.3% at bedside without a physician's order to keep the medication there. During an initial tour, the cream was observed in a plastic bag beside the resident in bed, and the resident stated she applied the cream to herself daily and that it had come from home and was given back to her by the nurse. An LVN later verified the cream was at bedside and stated it should not have been there. The resident's medical record showed a physician's order dated 4/17/26 to apply Zoryve External Cream 0.3% topically once daily, with a note that the family was to provide the medication. The record also showed the resident had decision-making capacity, but it did not contain a physician's order for self-administration of the cream or any documentation of an IDT assessment for self-administration of medications. Review of the TAR showed the cream was applied once daily, and the DON was informed of the findings.
Advance Directive Not Maintained in Resident Record
Penalty
Summary
The facility failed to obtain and maintain a copy of the Advance Directive for Resident 12. Review of the facility policy showed that on admission the facility was to determine whether a resident had executed an advance directive and, if so, make copies and place them on the chart. Resident 12 was admitted to the facility and, according to the H&P, could make needs known but could not make medical decisions. The medical record also included a Social Service Review stating that Resident 12 had issued an advance directive about care and treatment, but a copy was not found in the chart. The record did not show documented follow-up with the resident or the family representative to obtain the document. During interview and concurrent record review, the SSD stated that when a resident could not make health care decisions, the facility would ask the family for a copy of the advance directive and upload it to the medical record, but the SSD was unable to locate Resident 12's advance directive and acknowledged there was no documented follow-up. The DON was informed and verified these findings.
Incomplete Assessment of Transfer Pole Use
Penalty
Summary
Resident 6 was not completely assessed for functional use of a transfer pole. The resident was admitted with paraplegia and had intact cognition with a BIMS score of 14. The medical record showed the resident used a transfer pole in bed, and the resident stated the poles helped with turning and during care because of paralysis from the waist down. The facility’s accident prevention care plan identified the use of a transfer pole, but the OT evaluation and plan of treatment and the PT evaluation and plan of treatment did not reflect the transfer pole, its benefit, clinical justification, or appropriateness for the resident's use. The interdisciplinary resident screen later documented no significant decline in ROM, mobility, or ADL performance and indicated skilled PT/OT services were not indicated, with continuation of the restorative nursing program. However, the restorative nursing order addressed only lower extremity PROM and did not show PROM exercises for the upper extremities. During interviews, the DOR stated PT or OT should have assessed transfer pole use and that it should have been documented on the rehab evaluation and screening. The MDS Coordinator stated she should have completed and documented that part of the assessment on the MultiCare Conference Assessment and care plan, and the DON acknowledged the findings.
Failure to Provide Ordered Low Air Loss Mattress for Sacral Pressure Injury
Penalty
Summary
Failure to provide a low air loss mattress for Resident 49, despite a physician’s order for wound management, was identified during observation, interview, and medical record review. The facility’s Support Surfaces Guidelines stated that residents at risk for skin breakdown should be placed on a redistribution support surface such as a foam, gel, static air, alternating air, or air-loss surface when lying in bed. On 5/18/26, Resident 49 was observed in bed twice, and a low air loss mattress was not present; the same was observed again on 5/19/26. Resident 49 was admitted and later readmitted to the facility, had the capacity to make his own medical decisions, and had a sacral pressure injury documented in the record. The physician’s order dated 5/2/26 directed that he be placed on a low air loss mattress for wound management. The skin record showed an unstageable sacral pressure injury measuring 3 cm x 3 cm, and later documentation identified a stage 3 sacral pressure injury measuring 1 cm x 0.5 cm with additional care including a moisture barrier and pressure reducing devices for the bed and chair. LVN 3 and RN 5 both verified that Resident 49 was not provided a low air loss mattress, and RN 5 stated that such a mattress was an intervention to prevent pressure injuries from worsening.
Incomplete post-fall neuro checks and unsafe smoking practices
Penalty
Summary
The facility failed to ensure necessary care and services were provided after an unwitnessed fall for Resident 13. Resident 13 had severely impaired cognitive patterns with a BIMS of 00. After the fall on 5/7/26, the resident was found with a lip abrasion and light bleeding, and the physician recommended neurological assessments for 72 hours. The facility’s neurological flowsheet showed the scheduled neurological assessment entries were missing for multiple time intervals, including Q15x2, Q15x3, Q15x4, Q30x1, Q30x2, Q4x2, and Q8x2. The facility’s neurological assessment policy stated that neurological checks are to be conducted as frequently as ordered and that the date, time, all assessment data, and any refusal are to be recorded in the medical record. During interview and record review, RN 1 verified the missing neurological assessments and stated they were ordered to monitor the resident’s neurological condition after the unwitnessed fall and determine whether the resident remained at baseline. The DON also verified the missing entries and stated she expected every scheduled neurological assessment to be completed. The facility also failed to follow its smoking policy for Resident 79, who was assessed as needing supervision to smoke safely. Resident 79 was observed with a box of cigarettes in his shirt pocket and stated he could smoke and hold his own cigarette. The smoking policy stated that only residents with independent smoking privileges may keep cigarettes and other smoking articles in their possession, and residents without independent smoking privileges may not have or keep any smoking articles. Despite being identified as needing supervision and not being an independent smoker, Resident 79 was observed keeping cigarettes in his pocket, and staff interviews confirmed he kept his cigarettes with him while the lighter was stored separately.
Failure to Obtain Ordered Weekly Weights
Penalty
Summary
The facility failed to ensure that one of two final sampled residents reviewed for nutrition, Resident 49, received an acceptable nutritional service. The deficiency involved failure to monitor weekly weights as ordered by the physician. Facility policy stated that resident weights were monitored for undesirable or unintended weight loss or gain, and that residents were weighed upon admission and at intervals established by the interdisciplinary team. Resident 49 was admitted and later readmitted to the facility, and the H&P dated 5/4/26 showed the resident had the capacity to make his own medical decisions. The weight summary showed weights of 117 lbs. on 4/1/26, 113 lbs. on 4/7/26 and 4/12/26, 112 lbs. on 4/26/26, and 105 lbs. on 5/2/26 and 5/5/26, for a 10.26% weight loss from 4/1/26 to 5/5/26. The IDT Weight Management Update dated 5/6/26 documented a 12 lb. weight loss in one month and included weekly weights for four weeks as an intervention. A physician order dated 5/10/26 also directed weekly weights for four weeks, but on 5/19/26 the DSD verified the last weight obtained was 5/5/26, and the DON confirmed the weekly weight for the week of 5/12/26 was not obtained.
Failure to Document Baseline Midline IV Measurements
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the intravenous access for Resident 68, who had a midline IV in the left upper arm with two lumens and a transparent dressing. The resident had physician orders for antimicrobial disc use, routine flushing of the midline lumen, monitoring for inflammation or infiltration every shift, measuring arm circumference 5 cm above the insertion site during dressing changes, changing the midline dressing and Stat-lock weekly, and measuring the external catheter length during dressing changes with notification to the MD if the length increased by 2 cm or more. Medical record review showed no baseline documentation of the external catheter length or arm circumference above the insertion site when the resident arrived from the acute hospital where the midline was inserted. The resident’s care plan did not address the midline IV, and the IV Administration Record for April and May 2026 did not show baseline arm circumference or catheter length measurements documented on admission. During interview and record review, RN 1 confirmed the resident was receiving IV antibiotics through the midline and stated nursing staff were responsible for dressing changes and measurements, but could not verify any baseline measurements from the acute care hospital. The DON later reviewed and verified these findings.
Pain Management Not Provided as Ordered
Penalty
Summary
The facility failed to provide safe, appropriate pain management for Resident 49, who was admitted and readmitted to the facility and had diagnoses including sciatica and fibromyalgia. The resident’s H&P noted he had the capacity to make his own medical decisions. On 5/20/26, he was observed awake and lying in bed and stated he had pain in his left hip and had been waiting for a lidocaine patch he had requested. A physician ordered lidocaine external patch 4% to the resident’s left hip daily, to be removed after 12 hours, but the MAR showed the patch was not provided at the scheduled time and was coded as other. A progress note later documented that the patch was not available and was pending pharmacy delivery. During interviews, LVN 7 stated the patch had not been received because the pharmacy had not delivered it, and confirmed the order had been placed the day before. RN 1 stated newly ordered routine medications should arrive before the first scheduled dose and that licensed staff should follow up with pharmacy if the medication did not arrive on time. The DON stated routine medications were delivered four times a day and expected licensed staff to follow up if a medication was not delivered within the expected timeframe. Resident 49’s care plan addressed pain related to nerve pain, generalized body pain, leg pain, back pain, and left hip pain, and included administering medications as ordered, monitoring and documenting side effects and effectiveness, and providing nonpharmacological interventions such as repositioning, massages, or a comfortable environment. Review of the medical record did not show documented evidence that nonpharmacological interventions were provided before hydrocodone-acetaminophen was administered, and it also did not show monitoring of side effects of the pain medication. LVN 7 stated nonpharmacological interventions should be provided before pain medication and that side effects such as overdose should be monitored and promptly reported to the physician. RN 1 verified these findings, and the DON was informed and acknowledged them.
Inaccurate Dialysis Access Documentation
Penalty
Summary
The facility failed to ensure dialysis care and services were provided accurately for one resident who received hemodialysis three times a week and had a right upper chest Permacath. The resident’s physician orders included monitoring the dialysis site each shift for tenderness, redness, or bleeding and documenting findings outside of baseline, along with hemodialysis treatments every Monday, Wednesday, and Friday with Dialysis Center A. Review of the resident’s Dialysis Communication Record showed inaccurate documentation on multiple dates, with the pre-dialysis and post-dialysis sections indicating that bruit and thrill were present. During interviews and record review, an LVN confirmed the resident had a Permacath on the right upper chest wall and stated it was being monitored for redness, swelling, and bleeding, but also verified the record showed bruit and thrill present. The LVN further stated a Permacath has no bruit and thrill. An RN stated the resident had a right upper chest dialysis access and that monitoring included bruit and thrill, and another RN stated the resident had an AV shunt on the right upper chest and that the access was being monitored for bruit and thrill. The DON verified the resident’s dialysis access was a right upper chest Permacath and stated bruit and thrill would not be assessed for residents with a Permacath.
Staff Competency Deficiencies in Dialysis Access and Medication Administration
Penalty
Summary
The facility failed to ensure RN 1 and RN 2 were competent to assess the Permacath dialysis access for Resident 7. The record showed Resident 7 received hemodialysis every Monday, Wednesday, and Friday and had a Permacath on the right upper chest wall. RN 1 stated the access site was checked for redness, bleeding, swelling, pain, bruit, and thrill, and RN 2 stated the resident had an AV shunt on the right upper chest and that the access was monitored for bruit and thrill. The DON later stated Resident 7 had a right upper chest Permacath and that bruit and thrill would not be assessed for a resident with a Permacath, and acknowledged the findings. The facility also failed to ensure LVN 7 demonstrated competency in administering ophthalmic medication and nasal spray medication. The facility’s skill checklist showed competency for eye medications but did not include nasal spray administration. During medication administration for Resident 53, LVN 7 gave artificial tears to both eyes, waiting three minutes between the right and left eye doses, and administered fluticasone propionate nasal spray without asking the resident to blow his nose first. LVN 7 stated she had been trained by the pharmacy consultant to wait three to five minutes between eye drops and to have residents blow their nose before nasal spray administration, and the DSD confirmed the annual skills checklist did not include nasal spray medication.
Medication administration and controlled substance reconciliation failures
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to ensure accurate medication administration and reconciliation. During observation of medication administration for one resident with a gastrostomy tube, an LVN prepared insulin glargine, vitamin C, and Pro-Stat, used cold water from a pitcher to flush the GT, gave 10 ml of water with the vitamin C, flushed with 5 ml of water between medications, and then flushed with 30 ml of water before and after medication administration. The resident’s physician orders called for Pro-Stat Sugar Free mixed with water via GT and vitamin C via GT, and the facility’s policy required flushing with 15 ml of warm purified water between medications when more than one medication was administered through an enteral tube. The LVN later verified she had flushed with 5 ml of cold water between medications and had administered regular Pro-Stat instead of the ordered sugar-free product. For another resident, an LVN administered artificial tears to both eyes and waited three minutes between the same ophthalmic medication to each eye, which was consistent with the facility policy for eye drops. However, when administering fluticasone propionate nasal spray, the LVN did not ask the resident to blow his nose before the spray was given. The resident’s orders included fluticasone propionate nasal spray one spray to both nostrils daily and artificial tears twice daily for eye dryness. The LVN later confirmed she did not ask the resident to blow his nose before administering the nasal spray. The facility also failed to document administration of hydrocodone-acetaminophen for a resident with capacity to make decisions. The controlled drug record showed the medication was removed from the narcotic drawer on two occasions, but the MAR did not show that the medication was administered on those dates and times. In addition, the controlled medication reconciliation record for Station A, Cart A contained multiple missing licensed nurse signatures during shift counts. The facility’s controlled substances policy required end-of-shift controlled medication counts to be completed by the nurse coming on duty and the nurse going off duty, with both nurses documenting the count. The DON was informed of these findings and acknowledged them.
Failure to Document Monitoring for Eliquis Side Effects
Penalty
Summary
The facility failed to ensure that Resident 2’s drug regimen was free from unnecessary drugs by not documenting monitoring for side effects related to Eliquis use. Resident 2 was admitted to the facility and had the capacity to make his own medical decisions. The physician ordered Eliquis 5 mg by mouth twice daily for atrial fibrillation, and the resident’s care plan included interventions to administer the anticoagulant as ordered and to monitor for bruising and bleeding, including blood in urine or stool, unusual bleeding after shaving, bleeding from gums or nose, excessive bleeding from wounds, large hemorrhagic areas, and petechiae. Review of Resident 2’s medical record did not show documented evidence that he was monitored for signs and symptoms of bruising or bleeding related to Eliquis. During interview and concurrent record review, the LVN stated that Eliquis can cause bleeding and bruising and that a resident receiving an anticoagulant should be monitored for these symptoms. The LVN confirmed that Resident 2 had current orders for Eliquis and verified there was no documented evidence of monitoring for the medication’s side effects. The DON was informed of and acknowledged these findings.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent; the observed rate was 7.69%. During medication administration observation, LVN 7 was found to have errors with two residents. For Resident 60, LVN 7 prepared two tablets of one gram sodium chloride and administered the medication while the resident was sitting in a wheelchair, but there was no meal tray or food at the bedside and the nurse did not ask whether the resident had eaten. The resident's order summary showed a physician's order dated 12/7/25 for sodium chloride two grams by mouth with meals. During interview, LVN 7 verified that the medication had been given without meals and stated the resident had not eaten yet, with lunch expected later. For Resident 53, LVN 7 prepared medications that included a bottle of artificial tears containing glycerin, hypromellose, and polyethylene glycol. The resident's order summary showed a physician's order dated 5/19/26 for artificial tears ophthalmic solution (1-0.3% propylene glycol glycerin), one drop in both eyes twice daily for eye dryness. When interviewed, LVN 7 verified that she administered the artificial tears with glycerin, hypromellose, and polyethylene glycol instead of the ordered formulation. The DON was informed of these findings and acknowledged them.
Medication Room Left Open, Medications Stored Together, and Disposal Logs Missing Required Signatures
Penalty
Summary
Medication Room A in Station A was observed with a trash can propped against the door to keep it open during the initial tour. Inside the room were a medication emergency kit on the countertop, two refrigerators, medications, and syringes on the shelves. The room was located next to the emergency door exit and was open to enter the facility. RN 4 later verified that the medication room had been left open and stated it should not have been propped open with a trash can. The DON stated that licensed nurses were expected to keep the medication room locked at all times. Medication Room A also had internal and external medications stored together on the lower shelf. Calcium carbonate, diclofenac sodium gel, budesonide and formoterol fumarate dihydrate, mineral oil enema, and saline laxative enema were observed stored together, and LVN 7 verified that they were stored together and stated they should have been stored separately. In addition, the facility's Drug Destruction Log showed multiple medication destructions with only one nurse signature, and one log was undated with no signature of two nurses. LVN 7 verified the log entries and stated medication destruction should have been witnessed by two nurses and signed accordingly; the DON also stated that two licensed nurses were expected to sign the Drug Destruction Log.
Chopped Meat Diet Not Prepared as Ordered
Penalty
Summary
The facility failed to ensure that one resident’s ordered chopped meat diet was followed and prepared appropriately. The resident was ordered a regular diet with regular consistency, chopped meat texture, thin liquids, meat chopped, and 1:1 assistance. The resident had been admitted to the facility on 3/7/24, had capacity to understand and make decisions, and had a speech therapy evaluation showing risk for aspiration, immobility, and decreased ability to return to prior level of assistance. During lunch observation, the resident’s meat portion appeared as ground meat, and the CNA stated this was what the resident ate all the time. Facility staff later acknowledged the meal had a ground-like appearance and stated the apricot glazed pork loin mechanical soft recipe had been followed. The dietitian stated the resident was on a diet described as easy to chew and soft and bite sized, and also stated that if the diet ordered was chopped meat, the preparation was inaccurate. The DON later acknowledged that the meat served did not appear chopped.
Blood Glucose Meter QC Not Documented and Medication Refrigerators Had Ice Buildup
Penalty
Summary
The facility failed to ensure that the Assure Platinum Blood Glucose Monitor control was monitored for one of the two Assure Platinum blood glucose meters assigned to Medication Cart A. Facility records showed daily quality control documentation for Assure Platinum meter serial number 1040-4507209, but no quality control record was found for Assure Platinum meter serial number 1040-4427033. During a concurrent medication storage inspection, Medication Cart A was observed to contain both meters, and an LVN stated either meter was used to check residents' blood sugar levels. The LVN verified there was no documentation showing control testing for serial number 1040-4427033 and stated the other meter had been broken for a week. The DON stated licensed nurses were expected to complete control checks on all Assure Platinum meters being used. The facility also failed to keep the medication refrigerators in Medication Room A free from ice buildup. During a concurrent medication storage inspection, both medication refrigerators were observed with ice buildup in the freezer compartments, and the LVN verified the condition. The LVN stated the night shift usually defrosted the refrigerators. The DON stated licensed nurses were expected to keep the refrigerator clean and without ice buildup.
Failure to Obtain Proper Consent for Resident Photography and Social Media Posting
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ personal privacy and maintain confidentiality of medical and personal information when an outside performer recorded and posted videos of residents on social media without appropriate consent. Facility policies on confidentiality and on photography, video, audio, and electronic recordings required that release of resident information, including video, be handled in accordance with resident rights and that written consent be obtained from the resident or legal representative before taking any photographs or recordings for marketing or promotional purposes. Despite these policies, the Administrator stated she consented to the performer video recording the performance, including residents who attended the activity, without any restrictions and without verifying whether residents’ existing consents covered social media or activity performance recordings. For one resident with severe cognitive impairment (BIMS score 0), the medical record showed a Consent for Photography limited to use for the facesheet only, signed by the responsible party. The responsible party confirmed that he did not consent to any photography or video recording by the performer or to posting on social media, and reported that the posted photos and videos included humiliating comments. For another cognitively intact resident (BIMS score 13), the Consent for Photography allowed use for the facesheet, dietary card, and medication records only. This resident stated he did not consent to photography or video recording for social media and observed the performer recording the performance and residents with a personal phone, without expecting the recordings to be uploaded. The Admissions Coordinator, Administrator, and DON all verified that the consents for these residents did not include permission for social media use, confirming that the facility failed to follow its own consent requirements and resident-specific limitations on photography.
Failure to Provide and Document Required Written Transfer/Discharge Notices to Residents and Representatives
Penalty
Summary
The deficiency involves the facility’s failure to provide required written Transfer and Discharge Notices, including bed-hold and return policies, directly to residents and/or their representatives when residents were transferred to an acute care hospital. Surveyors cited SOM Appendix PP, F483.15(c)(3), which requires that before a transfer or discharge, the facility must notify the resident and the resident’s representative in writing and in a language and manner they understand. The facility’s own policy dated 10/2022 states that notice of transfer is to be provided to the resident and representative as soon as practicable before transfer, and that notice of bed-hold and return policies must be provided within 24 hours of an emergency transfer, with documentation in nursing notes of appropriate orientation and preparation of the resident. For one resident with severe cognitive impairment (BIMS score 0) who fell and had hypotension, the progress notes showed the responsible party was at the bedside during the transfer to the hospital. The Notice of Transfer and Discharge dated the same day was completed by an LVN and indicated that a written copy was provided to the responsible party, but the method documented was that it was sent with transfer paperwork to the acute hospital via paramedics. For a second resident, who had capacity to understand and make decisions and experienced a sudden change in mental status leading to transfer, the Notice of Transfer and Discharge was completed by an RN and also indicated that a written copy was provided to the responsible party, yet again the method documented was that it was sent with the transfer paperwork to the acute hospital. For a third resident with moderate cognitive impairment (BIMS score 9) who was transferred to the hospital after a fall with injury and later readmitted, the Notice of Transfer and Discharge completed by an RN had the section for “Written copy of the Notice of Transfer and Discharge Provided” left blank, while the method section showed it was sent with transfer paperwork to the acute hospital. During interviews, the DON and nursing staff described a practice of placing the Notice of Transfer and Discharge, along with other clinical documents, in an envelope given to paramedics for the hospital, while verbally informing residents or responsible parties of the transfer and bed-hold. The DON acknowledged that the notice, discharge, and bed-hold information were on one form and that the facility relied on verbal notification, and the RN who transferred one resident stated she verbally informed the responsible party and handed the notice to him but did not document this in the medical record. Another LVN stated she sent the notice with the hospital transfer records and did not confirm awareness of the facility’s policy, resulting in a lack of documented evidence that written notices were actually provided to the residents or their representatives as required.
Failure to Timely Report Resident's Sexual Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure for timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of sexual abuse made by a resident against a staff member. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but no later than two hours, to the appropriate authorities, including the State licensing/certification agency. In this case, the resident alleged that a Licensed Vocational Nurse (LVN) engaged in inappropriate physical contact, including positioning her vagina on the resident's elbow and straddling and thrusting against the resident. The resident reported the incident to a Certified Nursing Assistant (CNA), who then informed the LVN of the allegation. The LVN, who was the alleged perpetrator, did not report the allegation to a supervisor, stating she did not know how to report when she was involved in the incident. The facility reported the abuse allegation to the California Department of Public Health (CDPH) Licensing & Certification Program several days after the incident occurred, as evidenced by the SOC 341 form. The resident involved had a history of moderate cognitive impairment but was assessed as having the capacity to understand and make decisions. Interviews with the resident, CNA, and LVN confirmed the sequence of events and the delay in reporting. The administrator acknowledged the findings during the survey. The failure to report the allegation in a timely manner was a direct violation of the facility's own policy and regulatory requirements.
Deficient Kitchen Sanitation and Equipment Maintenance
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's kitchen related to food safety and sanitation. During an initial kitchen tour, numerous kitchen utensils, including scoops, spatulas, serving spoons, and measuring spoons, were found to be dirty with dry crusted residue, watermarks, and fuzzy films. These utensils were not clean to sight and touch, and the Dietary Services Supervisor (DSS) acknowledged that they needed to be rewashed and air dried to prevent cross contamination and bacteria growth. Additionally, several utensils were observed to be in poor condition, such as being discolored, peeling, burnt, deformed, or worn out, which compromised their ability to be properly cleaned and maintained as required by facility policy and the USDA Food Code. Further observations revealed that some heavy-duty blenders, clear plastic pitchers, and a measuring pitcher used for beverages were stored while still wet and stacked on top of each other, rather than being air dried as required. The DSS confirmed that all kitchen utensils and equipment should have been air dried to prevent bacteria growth. The kitchen hood over the stove was also found to have black dirt and greasy residue, despite a cleaning schedule and recent service by an outside company. The DSS acknowledged that the hood should not have greasy residue due to fire hazard and contamination risks. A review of facility policies and procedures, as well as relevant USDA Food Code sections, confirmed that the observed practices did not meet required standards for cleanliness, maintenance, and storage of kitchen equipment and utensils. The deficiencies were noted to have the potential for cross contamination and foodborne illnesses for the residents consuming food prepared in the facility's kitchen. At the time of the survey, 69 of 72 residents were consuming food prepared in the kitchen.
Failure to Assess and Document Resident Self-Administration of Medication
Penalty
Summary
The facility failed to determine if it was safe for a resident to self-administer medication, as required by its own policy and regulatory standards. During an observation, a resident was found with a medication cup containing Diclofenac Sodium topical gel 1% at the bedside, which the resident stated was left by nursing staff for later self-application. The nurse present confirmed that licensed staff were not supposed to leave medications at the bedside, indicating a deviation from established procedures. A review of the resident's medical record revealed there was no physician's order, assessment, or care plan authorizing or addressing self-administration of medication. The resident's history and physical examination indicated the capacity to understand and make decisions, but there was no documentation of an interdisciplinary team assessment to determine if self-administration was clinically appropriate or safe. The Director of Nursing confirmed the absence of required documentation and orders for self-administration of medications for this resident.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of nineteen sampled residents, as required by facility policy and individual care plans. For one resident with decision-making capacity, the call light was observed on the floor under the bed, out of reach, and the resident was unable to locate or use it. This was confirmed by both the resident and an LVN, who acknowledged the call light was not accessible and stated that it should be within reach for resident safety and communication. For another resident with severe cognitive impairment and a history of neurological weakness and confusion, the call light was found clipped to the wall, also out of reach. The resident was unable to locate or use the call light to request assistance and did not know who had placed it there. This was similarly confirmed by an LVN, who stated the call light should be accessible, and by the DON, who verified the findings. Both residents had care plans specifying that call lights should be within reach, but these interventions were not followed.
Failure to Develop Comprehensive, Individualized Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, as required by their own policies and regulatory standards. For one resident, the care plan addressing mood and behavioral symptoms did not include all interventions listed in the resident's Informed Consent Renewal for psychoactive medications. Specifically, non-pharmacological interventions such as encouraging exercise, empathetic listening, individualization of care choices, positive reinforcement, repositioning, and social service or activity visits were documented in the consent form but were not reflected in the resident's care plan. Interviews with facility staff, including an LVN and the MDS Coordinator, confirmed that these interventions were practiced but not formally included in the care plan documentation. For another resident, the facility did not develop a care plan that addressed the recommendations from a PASARR Level II evaluation. The PASARR Level II evaluation, conducted by a psychologist, outlined several personalized care recommendations, including ongoing psychotropic medication monitoring and education, mental health rehabilitation activities, ADL training, supportive services, psychotherapy or counseling, psychiatry consultation, and neuropsychology consultation. Despite these recommendations and the resident's medical history of anxiety disorder, depressive disorder, and bipolar disorder, the care plan did not reflect these individualized interventions. Facility staff, including the MDS Coordinator, Administrator, and DON, verified during interviews and record reviews that the care plans for both residents were incomplete and did not incorporate all required interventions. These omissions were identified through observation, interviews, medical record reviews, and review of facility policies and procedures.
Improper Medication Storage and Expired Supplies
Penalty
Summary
The facility failed to ensure that medications and biologicals were handled securely, accurately labeled, and stored appropriately, as required by their own policies and professional standards. During an observation, a crash cart was found to contain two packages of a biohazard spill kit that had expired over five years prior. The contents of these kits included disposable gloves, absorbent towels, disinfectant wipes, hand sanitizer wipes, a plastic scoop with scraper, absorbent powder, a twist tie, and a red biohazard trash bag. The MDS Coordinator confirmed that these expired medical supplies should have been disposed of. In a separate observation, a medication cart was found with an unlocked transparent box compartment attached to its side. Inside, two packets of hydrocortisone acetate cream 1% were stored together with multiple packages of food thickener, a tape measure, medication label directions, and batteries. The MDS Coordinator acknowledged that the cream should have been locked in the treatment cart and not stored with food or other items, verifying the improper storage and lack of security for these medications.
Inaccurate POLST Documentation for Advance Directive
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the documentation on the resident's Physician Orders for Life-Sustaining Treatment (POLST) form. Review of the medical record revealed that the POLST indicated the resident's advance directive was not available, despite the fact that a Durable Power of Attorney had been uploaded into the electronic medical record prior to the completion of the POLST. During interviews, facility staff confirmed that the POLST should have reflected the presence and review of the advance directive, but this was not accurately documented. This inaccuracy was verified by both the Social Services Director and the Director of Nursing during the survey.
Infection Control Deficiencies: Inadequate Disinfection, Antibiotic Stewardship, and Legionella Surveillance
Penalty
Summary
The facility failed to maintain its infection prevention and control program as required by its own policies and CDC recommendations. During an observation, an LVN picked up a call light from the floor in a resident's room and placed it on the resident's bed without cleaning or disinfecting it, despite facility policy requiring such items to be cleaned after contact with the floor. The LVN acknowledged the oversight when informed, and the DON verified the incident. Additionally, the facility did not ensure that infection surveillance data for the antibiotic stewardship program was properly communicated to the physician. A resident was prescribed antibiotics for a suspected UTI, but the resident did not meet McGeer's Criteria for a true infection. There was no documentation that the physician was notified about the signs and symptoms or that the criteria for infection were not met, as confirmed by both the Infection Preventionist and the DON. The facility also failed to screen pneumonia cases for possible Legionnaire's disease, as required by its Legionella surveillance policy. Multiple cases of healthcare-associated pneumonia were identified over several months, but there was no coordination between the Infection Preventionist and the Maintenance Director regarding Legionella testing or discussion of pneumonia cases in infection control meetings. The last water system test for Legionella was conducted in the previous year, and the Maintenance Director only performed testing when instructed by the Administrator.
Failure to Follow Prescribed Portion Sizes for Pureed Mandarin Oranges
Penalty
Summary
The facility failed to ensure that menus were followed and residents' nutritional needs were met when the correct portion sizes for pureed Mandarin Oranges were not adhered to during meal preparation. Specifically, during an observation of puree preparation, dietary staff used a number 8 scoop (four ounces) instead of the required number 10 scoop (three ounces) as specified in the facility's recipe and portion control policy. This resulted in residents receiving a larger portion than planned. The Dietary Services Supervisor (DSS) acknowledged that the dietary staff did not follow the established portion size guidelines and should have used the correct scoop as indicated on the facility's spreadsheet and policy.
Failure to Revise Care Plans for Individual Resident Needs
Penalty
Summary
The facility failed to revise and update comprehensive care plans to address the individual care needs of two residents. For one resident, the care plan included interventions for fragile skin that required monitoring the effectiveness of zinc oxide cream treatment. However, medical record reviews and staff interviews revealed that the effectiveness of the treatment was not being evaluated or documented, despite the care plan's directive. Staff, including LVNs and the DON, confirmed that maintenance treatments were not evaluated for effectiveness, and the care plan intervention to monitor effectiveness was not being followed or considered necessary. For another resident, the care plan included an intervention to encourage verbalization of feelings, despite documentation and staff interviews indicating the resident had no capacity to understand or make decisions and was rarely or never understood. The resident was unable to verbalize needs, and staff acknowledged that the intervention was not realistic or appropriate for the resident's current cognitive status. The care plan had not been updated to reflect these changes, and the intervention remained inaccurate.
Failure to Change Enteral Water Feeding Bag Within 24 Hours
Penalty
Summary
A deficiency was identified when the facility failed to provide necessary gastrostomy tube (GT) care and services for a resident receiving enteral feeding. Specifically, the facility did not change the resident's enteral water feeding bag within the required 24-hour period, as outlined in the facility's policy and procedure for enteral feedings. The policy, revised in November 2018, states that administration sets for open-system enteral feeding must be changed at least every 24 hours or as specified by the manufacturer. The resident in question had a medical history of dysphagia and lacked the capacity to make decisions. Medical orders indicated the resident was to receive Diabetisource AC formula and free water via GT. During an observation, it was noted that the enteral feeding water bag had been prepared more than 24 hours prior, and this was confirmed by an LVN, who acknowledged the bag should have been changed within the 24-hour timeframe. The DON also verified and acknowledged these findings.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information, including the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted as required. During an observation and interview, a registered nurse and a licensed vocational nurse were unable to locate the posted staffing information at the nursing station. Both staff members confirmed that the information, which should have been available, was missing and could not be found at the time of the surveyor's request.
Failure to Properly Label and Document IV Site for a Resident
Penalty
Summary
A deficiency was identified when a resident receiving intravenous (IV) antibiotic therapy for a left lower leg venous ulcer/cellulitis did not have their peripheral IV (PIV) site properly labeled according to facility policy. During an observation, the PIV label was found to be missing the time of insertion, the initials of the staff member, and the length and gauge of the catheter. The registered nurse present confirmed these omissions. The facility's policy required that the label include the date and time of insertion, initials, and catheter details, but these were not present on the observed label. Further review of the resident's medical record and IV administration record revealed inconsistencies regarding documentation of the IV site change. Although the label on the IV site indicated a change on a specific date, there was no corresponding documentation in the nurse's notes or IV administration record to confirm that the site was changed as required. The Director of Nursing verified the absence of this documentation during a review.
Failure to Label and Date Nasal Cannula for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care in accordance with its own policies and procedures for one resident with a diagnosis of COPD. The facility's policy required that nasal cannulas be labeled or dated when changed or replaced, and that oxygen tubing be changed weekly. During an observation, a resident was seen using a nasal cannula that was not labeled with the date, and this was confirmed by an RN, who acknowledged that the lack of labeling could prevent staff from knowing when to change the cannula. The DON was also informed and verified these findings. The resident had a physician's order for oxygen to be administered via nasal cannula as needed, based on oxygen saturation levels.
Incorrect Dosage of Zinc Sulfate Administered
Penalty
Summary
A deficiency occurred when LVN 8 failed to administer zinc sulfate to a resident as ordered by the physician. During a medication administration observation, LVN 8 provided the resident with a 50 mg tablet of zinc sulfate instead of the prescribed 220 mg tablet. This discrepancy was confirmed through medical record review and direct interview with LVN 8, who acknowledged the error. The facility's policy and procedure for administering medications requires that medications be given in accordance with the prescriber's orders, including the correct dosage and timing. The resident involved had a history and physical examination indicating capacity to understand and make decisions. The physician's order for zinc sulfate 220 mg daily was clearly documented in the resident's order summary report. The Director of Nursing (DON) reviewed the findings and confirmed that the licensed nurse should have checked both the physician's order and the medication prior to administration. The failure to administer the correct dosage of zinc sulfate as ordered constituted a lapse in following established medication administration protocols.
Improper Storage of Garbage in Facility Dumpsters
Penalty
Summary
The facility failed to ensure proper storage and disposal of garbage in both of its outside dumpsters. Observations revealed that one dumpster lid was partially propped open by bulky boxes, and on a separate occasion, another dumpster lid was prevented from fully closing due to trash bags. These conditions were confirmed by the Maintenance Director, who acknowledged that the dumpster lids should be completely closed for infection control purposes. A review of the facility's policies and procedures indicated that all waste, including kitchen and infectious waste, should be disposed of in a safe and appropriate manner, with garbage containers kept in good condition and tightly closed. The FDA Food Code also requires outside garbage receptacles to have tight-fitting lids to prevent pest and rodent entry. The facility's failure to keep dumpster lids closed was directly observed and verified during the survey.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. This failure occurred when the facility did not report an allegation of abuse involving a resident to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program in a timely manner. The facility's policy on abuse prevention and mandated reporting requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the state licensing/certification agency. Allegations resulting in serious bodily injury must be reported within two hours, while other allegations must be reported within 24 hours. In this case, a resident, who was cognitively intact with a BIMS score of 15, alleged that she was abused in the facility because her meals were not delivered, staff were not answering her call lights, and she was being retaliated against. The facility attempted to report the abuse allegation on the same day it was made, but the fax containing the report was mistakenly sent to the facility's own fax number instead of the CDPH, L&C Program's fax number. This error was confirmed during an interview with the Administrator, who verified that the fax transmission log showed the report was sent to the incorrect number.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation standards in the kitchen, as observed during a survey. The deficiencies included improper monitoring of Time/Temperature Control for Safety (TCS) foods, which are crucial to prevent the growth of bacteria that can cause foodborne illnesses. Specifically, the facility did not document or monitor the cooling process of hot dogs served to residents, which should have been recorded in the Cooling Log. This oversight was confirmed by the Dietary Services Supervisor (DSS), who acknowledged that the hot dogs were not properly monitored after being served. Additionally, the facility did not ensure proper hand hygiene practices among dietary staff. An employee was observed changing tasks and handling clean dishes without washing hands between glove changes, which is a critical step to prevent cross-contamination. The DSS confirmed that the staff did not follow the hand hygiene policy, which requires washing hands before donning new gloves and between different tasks. The facility also failed to maintain proper labeling and storage of food items. Several items in the refrigerator were not labeled with open or use-by dates, and some food past its use-by date was not discarded. Furthermore, kitchen equipment and utensils were not stored in sanitary conditions, with some items found wet and with food residues. The DSS verified these findings and acknowledged that the equipment should be properly cleaned and air-dried before storage. These lapses in food safety and sanitation practices had the potential to cause foodborne illnesses among the residents.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, impacting their ability to access necessary assistance. Resident 115's call light and bed remote control were found hanging on the bedside drawer handle, out of the resident's reach, during an initial tour. This was confirmed by RN 1, who acknowledged that these items should have been placed within the resident's reach on the bed. Resident 115 was observed sleeping at the time of the tour, and the medical record review indicated the resident had been admitted and readmitted to the facility on unspecified dates. Similarly, Resident 3's call light was observed on the floor during the initial tour, making it inaccessible to the resident. This observation was verified by LVN 4, who confirmed that the resident would not be able to reach the call light in its current position. A subsequent observation the following day found the call light still on the floor, with the DON verifying that Resident 3 would not be able to reach it. These deficiencies in ensuring call lights and bed controls were within reach had the potential to negatively impact the residents' psychosocial well-being or delay their receipt of care.
Failure to Notify Resident's Representatives and Ombudsman of Transfer
Penalty
Summary
The facility failed to notify a resident's representatives and the Office of the State Long-Term Care Ombudsman in writing about the resident's transfer to an acute care hospital. This deficiency was identified for one of the two sampled residents reviewed for hospitalization. The facility's policy and procedure for transfer or discharge, dated October 2022, requires that residents and their representatives be notified in writing of the specific reason for transfer, the effective date, the location to which the resident is being transferred, and the resident's right to appeal the transfer. Additionally, the policy mandates that a copy of the notice be sent to the LTC Ombudsman. In the case of the resident involved, the medical record review revealed that the resident lacked the capacity to understand and make decisions. Physician orders indicated transfers to the acute care hospital on two separate occasions. However, the medical records did not contain written notifications of these transfers to the resident's representatives or the LTC Ombudsman. Interviews with the RN and the Medical Records Department (MRD) confirmed the absence of these notifications. The MRD acknowledged the responsibility to send these notices but failed to do so for the identified transfer dates.
Failure to Provide Written Bed Hold Policy
Penalty
Summary
The facility failed to provide a written bed hold policy to the resident's representative upon the transfer of a resident to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, which require that residents and their representatives be notified in writing of the bed hold policy when a transfer occurs. The review of the medical records for a specific resident, who lacked the capacity to understand and make decisions, revealed that the required written notices were not provided during two hospital transfers. Interviews with facility staff, including a registered nurse and a member of the Medical Records Department (MRD), confirmed the oversight. The MRD acknowledged that it was their responsibility to send the written bed hold policy to the resident's representative upon transfer, but they were unable to provide evidence that this was done for the transfers in question. This failure to provide the necessary documentation had the potential to leave the resident's representative uninformed about their rights regarding the resident's return to the facility after hospitalization.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,858 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Anaheim Medical Center D/p Snf | 0 mi | ★★★★★ | 16 | 0 |
| Beach Creek Post-acute | 0.6 mi | ★★★★★ | 28 | 0 |
| Anaheim Healthcare Center, Llc | 0.6 mi | ★★★★★ | 3 | 0 |
| Anaheim Terrace Care Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Park Anaheim Healthcare Center | 0.8 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.