Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Anaheim Healthcare Center, Llc during CMS and state inspections, most recent first.
Missed Shower Care and Documentation Three residents had repeated shower refusals or missing shower skin inspection documentation, and the chart lacked evidence of care plan updates, intervention documentation, or RP notification tied to the refusals. One resident had moderate cognitive impairment, another had severe cognitive impairment with a rash and topical steroid order, and a third lacked capacity and also had a rash with a topical steroid order. Staff confirmed the missing documentation and described the expected shower documentation process, including CNA completion of shower skin inspection sheets and nurse follow-up for refusals.
Incomplete informed consent for psychotropic medications: The facility did not ensure that consent forms for several residents included required details such as the diagnosis, behavior manifestation, indication, or duration of use for psychotropic drugs. One resident also had no documented consent for a PRN anxiolytic, and another resident's telephone consent for an antipsychotic was verified by only one RN instead of two as required by policy.
The facility failed to maintain a homelike environment in two rooms where a resident’s closet door, walls, and bedside drawer had chipped or peeled paint, and another resident’s wall also showed chipped paint. The facility also failed to properly investigate missing personal property for a resident who reported a missing heart monitor, mattress, tennis shoes, back brace, and money; staff acknowledged some items were missing, but documentation and follow-up were incomplete.
Psychotropic Medication Monitoring and Documentation Failures: The facility failed to document required behavior monitoring and nonpharmacological interventions for a resident receiving antipsychotic and antidepressant medications, failed to show ordered nonpharmacological attempts before olanzapine for another resident, and failed to complete ordered monitoring for residents receiving trazodone, escitalopram, and Risperdal. Records showed missing shift documentation, absent side-effect checks, and inaccurate orthostatic BP readings, with the ADON and DON verifying the findings.
Surveyors found that several residents’ care plans were not updated to reflect current orders or status. One resident’s pain plan did not include ordered nonpharmacological interventions before PRN analgesic use, another resident’s oxygen plan did not specify the current O2 flow rate, a third resident’s fluid restriction plan still listed an outdated amount, and a fourth resident’s antidepressant-related care plan used the wrong behavior manifestation. RNs and the DON acknowledged the discrepancies.
The facility failed to rotate insulin injection sites for two residents with DM, with MAR documentation showing repeated injections in the left lower quadrant of the abdomen for both basal and sliding-scale insulin. The facility also failed to continuously monitor a resident after an unplanned 7-lb weight loss, even though the change in condition was documented and added to the care plan.
Failure to Monitor Weight Loss and Fluid Restriction: A resident with severe malnutrition had poor PO intake and major weight loss that was not timely assessed, reported, or reflected in the care plan, while another resident’s RD-recommended snacks and weekly weights were not promptly carried out after a 7-lb. loss. In addition, a resident with a 2000 ml/day fluid restriction was given a bedside water pitcher and the fluid totals were not fully documented, with recorded intake exceeding the ordered limit on multiple occasions.
Incomplete GT Feedings and Water Flushes A facility failed to provide the full ordered GT enteral feedings and water flushes for four residents. Residents were observed with feeding pumps in place, but pump histories showed incomplete delivery of formula and water flushes compared with physician orders. One resident with dysphagia and no capacity for medical decisions also had an RD recommendation to increase the enteral feeding that was not followed up with the physician.
Failure to Provide and Document Pain Management Interventions: The facility did not document nonpharmacological pain interventions before giving PRN pain meds to two residents, gave one resident Norco outside the ordered pain range, and gave another resident acetaminophen for severe pain even though the order was only for mild pain. The DON and ADON verified the MAR and order discrepancies, and one resident was alert and oriented while another had no capacity to make decisions.
The facility failed to accurately monitor fluid intake and dialysis access care for three residents receiving HD. For two residents with AV access, CNA meal-fluid documentation did not match the nurses’ Monitor Record, access checks were inconsistent, and repeated pain at the access site was documented without evidence of notification to the MD, dialysis facility, or nephrologist. For a resident with a Permacath, staff observed extra fluids at the bedside, no CNA fluid documentation was present, and the room contained a dialysis kit with supplies that were not appropriate for that access type.
Kitchen staff failed to demonstrate proper competency in manual ware washing, sanitizer testing, and hand hygiene. Two dietary aides did not follow correct 2-compartment sink procedures when cleaning pans and knives, a cook did not accurately test sanitizer concentration using the test strip and color chart, and two staff members handled food and clean equipment without proper hand hygiene after glove removal or contact with raw chicken.
Kitchen food safety and sanitation practices were not followed. Staff did not monitor cooling for TCS foods, and salads were observed at unsafe temperatures without a cool down log. Two kitchen employees failed to perform proper hand hygiene during food handling tasks, thawing procedures were not labeled, manual ware washing was done incorrectly, and clean utensils were stored in dirty uncovered bins. In addition, a dietary manager was not wearing a beard restraint, wet equipment was stored without air drying, cutting boards were heavily marred or soiled, and can opener blades were worn and not clean.
Unsafe Handling of Outside Food Brought for Residents: The facility allowed residents and families to bring in outside food and store it in a designated refrigerator, but staff did not provide education on safe food handling practices. RN and DON interviews showed the only guidance given involved storage timeframes for food, while education on temperature control, transport, and other safe handling practices was not provided.
The facility’s Facility Assessment did not include active involvement from required direct care staff, resident, resident representative, or family participants, and it also lacked a plan to maximize recruitment and retention of direct care staff and a contingency plan for staffing needs. The Administrator verified the omissions and stated she was not aware of the current CMS guidance, confirming the assessment had not been updated to reflect the latest requirements.
The facility failed to accurately carry out its infection prevention and control surveillance program. The IP based surveillance only on residents prescribed antimicrobials and did not include residents with signs and symptoms of infection who were not on antibiotics. Monthly infection surveillance reports did not match the logs, and several residents were documented as having true infections without the required supporting criteria such as urine cultures, chest x-ray findings, or stool testing. The IP and DON acknowledged the surveillance determinations were incorrect.
The facility failed to complete the required infection screening and antibiotic time-out process for a resident who was prescribed azithromycin, and the resident’s record did not show documentation that the infection was evaluated for a true infection. Review of antibiotic time-out forms for nine other residents showed their infections did not meet McGeer’s criteria, yet they still received antimicrobial therapy and the forms did not indicate DNMC. The IP and DON were interviewed and the findings were verified.
A facility failed to properly document and align pneumococcal vaccine consent and administration for three sampled residents. One cognitively intact resident consented to PCV21 but received PCV20, while two residents with impaired decision-making capacity had representative-signed consents that did not specify the vaccine type even though both received PCV20. The IP verified the consent gaps and the DON acknowledged the findings.
Ice machine and ice storage bin sanitizing instructions were not followed. The Maintenance Director stated he used Scotsman Clear 1 Scale Remover mixed with water for both cleaning and sanitizing the ice machine and the ice storage bin, but the manufacturer guidelines required a locally approved sanitizer for sanitizing and thorough washing of the bin’s interior surfaces. After review of the instructions, the Maintenance Director verified the equipment was not being sanitized per the manufacturer’s directions.
A facility failed to determine whether two residents were safe to self-administer medications left at the bedside. One resident had vitamin C in the room despite an assessment stating the resident was not capable of safely self-administering meds, and there was no MD order or care plan for self-administration. Another resident with moderate cognitive impairment had five vials of refresh eye drops at the bedside, but there was no MD order, assessment, or care plan for self-administration, and the resident could not recall how often the drops were used.
Failure to notify physician and responsible party of significant weight loss: A resident with severe protein-calorie malnutrition and fluctuating capacity had a 24 lb. weight loss with poor PO intake documented, but the Change in Condition evaluation did not show that the MD was informed of the current weight or the full extent of the loss. Interviews with the ADON and DON confirmed there was no documentation that the physician or responsible party were notified of the significant weight change.
The facility failed to accurately code MDS assessments for three residents. One resident with severe protein-calorie malnutrition had documented significant weight loss that was not reflected in the MDS, another resident’s MDS did not capture insulin use and incorrectly listed anticonvulsant use, and a third resident’s MDS did not code subcutaneous enoxaparin injections despite MAR documentation.
A resident with bilateral hearing loss and bilateral hearing aids did not have a comprehensive care plan addressing impaired communication or hearing aid use. The resident told the surveyor he could not hear clearly and said his hearing aids were broken and not being fixed. An LVN confirmed the resident was hard of hearing, one hearing aid was broken, and no care plan had been developed to address the issue; the DON acknowledged the finding.
A resident at risk for pressure injuries was found in bed with an LAL mattress set in static mode and with no comfort-setting light showing, despite an order for the mattress for skin management and comfort care. The resident had a healed stage 3 sacral pressure injury history and a Braden score indicating risk. Staff confirmed the mattress should have been set according to the resident’s weight, but it was not.
A resident receiving continuous oxygen was observed with oxygen tubing and a nasal cannula that were not labeled with a change date, and no "Oxygen In Use" sign was posted outside the room. RN verified the resident had no physician order for oxygen therapy, despite the resident being on 4 L/min continuous O2. The DON confirmed the missing order, unlabeled tubing, and absent signage.
A resident was given a crushed delayed-release Depakote tablet even though the label said not to crush or chew it, and an LPN stated she was not trained on what DR meant. Another resident with COPD received arformoterol nebulizer treatment at noon instead of in the morning as required by the package insert, despite the MAR and order for twice-daily treatment.
The facility failed to ensure the consultant pharmacist identified and reported medication irregularities during MRR for two residents. One resident with COPD was ordered roflumilast 250 mcg daily, but the pharmacist verified the manufacturer’s maintenance dose is 500 mcg daily and no recommendation was documented. For another resident, the pharmacist noted persistently elevated SBP readings and advised notifying the physician about possible antihypertensive changes, but the DON could not show the physician was informed and the recommendation was not acted upon.
A resident with moderately impaired cognition received atenolol and benazepril even when pulse rates were below ordered hold parameters, and another resident taking potassium chloride with an ACE inhibitor did not have potassium levels closely monitored. RN and DON interviews confirmed the medication administration and lab review issues, and the consultant pharmacist noted the combination could increase potassium levels.
Unlabeled medications were found in medication carts, including an opened fluticasone nasal spray bottle and three opened artificial tears bottles without resident-specific identification. An LVN verified the nasal spray belonged to one resident and the eye drops belonged to three residents, while record review showed orders for artificial tears for two residents and no order for one resident. Staff and the DON stated the bottles inside opened medication cartons were expected to be labeled with the resident's name and date.
Dietary Manager credential lapse and inadequate RD oversight: The facility did not ensure the Dietary Manager met CDM qualification and continuing education requirements, and he was not listed as a current CDM on the ANFP website. The RD was responsible for oversight of dining services, but surveyors found multiple kitchen practice failures, including improper cooling, hand hygiene, thawing, ware washing, sanitation, hair restraints, and equipment cleanliness. The RD’s monthly QA reviews had marked these areas satisfactory despite the deficiencies later observed.
Incomplete COVID-19 Vaccine Consent Documentation: A resident with severely impaired cognitive skills had a COVID-19 vaccine consent signed by the resident representative, but the form left the vaccine brand blank even though the MAR showed Spikevax (Moderna) was administered. Facility policy required education on the risks, benefits, and side effects of the vaccine and identification of the vaccine type on the consent form; the IP verified the omission and the DON acknowledged the finding.
A resident with an indwelling urinary catheter was observed with the drainage bag and tubing touching the floor and not inside a dignity bag, contrary to facility policy and CDC guidelines. Both an LVN and the DON confirmed the improper placement and lack of adherence to catheter care protocols.
A resident with an indwelling urinary catheter was observed with the urinary drainage bag and tubing touching the floor and the drainage bag not placed inside a privacy bag, making the urine contents visible to anyone entering the room. Staff confirmed this was not in accordance with facility policy, which requires catheter drainage bags to be covered at all times to maintain resident dignity and privacy.
A resident on contact precautions for C. diff infection did not have the correct signage posted at their room, and an Activity Assistant entered the room without donning the required PPE (gown and gloves), contrary to facility policy. The Infection Preventionist confirmed the signage should have indicated contact precautions and that all staff must wear PPE when entering the room.
Surveyors observed that food and drink served to residents was not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency for the facility.
A resident on a no salt added diet did not receive the full prescribed breakfast menu, missing both the breakfast meat of choice and seasonal fruit cup due to a late delivery and lack of communication. The dietary staff acknowledged the menu was not followed, and the resident confirmed she did not receive all menu items.
A resident who could not make medical decisions had bilateral bolster pillows in use following a fall, but the medical record lacked a signed provider consent and a physician's order for the intervention. Both an LVN and the DON confirmed these requirements were not met, and facility policy was not followed.
A CNA failed to follow facility policy by pouring hot water into a resident's colostomy bag in an attempt to clean it, resulting in the bag touching the resident's skin and causing a burn injury. The resident experienced pain, redness, and a blister on the thigh, requiring pain medication and wound care. Staff interviews confirmed that the CNA did not adhere to established protocols, and the incident led to a documented wound.
A nurse aide, lacking proper training and competency in colostomy care, attempted to empty a resident's colostomy bag by pouring hot water into it, contrary to facility policy. This action caused the resident to sustain a burn and blister on the thigh and abdomen. The aide had not received formal instruction on the procedure and learned incorrect techniques from other staff, leading to the incident and subsequent injury.
Due to a kitchen equipment malfunction, lunch meals were not served at the scheduled time to the majority of residents. Several residents, including those requiring insulin or medications with meals, experienced significant delays, hunger, and frustration. Staff did not inform residents of the delay, and some required additional monitoring or snacks as a result.
Surveyors found multiple food safety and sanitation deficiencies, including unlabeled and expired food items in refrigerators, dirty surfaces in food storage areas, and improper storage of utensils. The majority of residents received food from the kitchen where these issues were observed, and facility policies requiring proper labeling, dating, and cleaning were not followed.
Several residents, including those lacking decision-making capacity, did not have properly completed informed consent forms for medications and treatments. Required signatures, dates, and witness information were missing or incomplete, and the facility's process for involving the IDT and Ombudsman was not followed as per policy. Staff interviews confirmed that consent documentation was not handled according to established procedures.
A resident with a physician's order for one-to-one feeding assistance due to aspiration precautions was observed eating independently and coughing while swallowing, without staff present. The care plan addressing nutrition was not revised to include the required intervention, as confirmed by the DON.
Several deficiencies were identified, including improper monitoring for orthostatic hypotension due to incomplete BP measurements and lack of notification parameters, failure to provide required one-on-one feeding assistance for a resident at risk of aspiration, and repeated BP measurements taken from the restricted arm of two residents with dialysis access devices, despite clear orders and facility policy. Staff interviews confirmed a lack of understanding and adherence to proper procedures.
A resident with dysphagia and Alzheimer's disease, who had a physician's order for one-to-one feeding assistance due to aspiration precautions, was observed eating lunch alone and unsupervised. The resident's diet slip did not reflect the required supervision, and staff interviews revealed a lack of awareness of the order, resulting in the resident consuming food and drink independently while intermittently coughing.
Surveyors identified multiple failures in respiratory care, including unlabeled and undated nebulizer and suction equipment, improper storage of suction devices, administration of oxygen therapy without proper physician orders or documentation, and failure to date an oxygen humidifier bottle. These deficiencies were confirmed by nursing staff and the DON during observations and record reviews.
The facility did not ensure proper medication administration and documentation for three residents, including failure to accurately sign out and dispose of a narcotic, administering a bowel medication without assessing for loose stool as ordered, and giving an antihypertensive medication despite blood pressure parameters that should have led to the dose being held. Staff and DON confirmed these deficiencies during interviews and record reviews.
Surveyors found that arformoterol was not stored per manufacturer instructions, with both opened and unopened vials kept in medication carts instead of a refrigerator, and staff did not monitor cart temperatures. Expired medical supplies and medications, including povidone-iodine swab sticks, a disinfectant bottle, and COVID-19 test kits, were not properly discarded from medication carts and storage rooms. Medication carts were also observed to be unsanitary, with sticky residues and dried medication present, and staff confirmed these conditions did not meet facility policy.
A resident with decision-making capacity did not receive a requested tuna melt as a replacement for the posted lunch entrée, despite the request being documented. Staff interviews confirmed the special request was missed, and the resident was served the standard menu items instead.
A resident with fluctuating decision-making capacity was not provided with their preferred Vietnamese menu during a meal, despite their care plan and facility policy requiring food preferences to be honored. Instead, the resident was served ice cream and verbally requested the preferred food, which was not provided by staff.
Several residents had inconsistencies in their medical records, including mismatches between documented decision-making capacity and responsible party status, lack of updates to H&P exams after cognitive reassessment, and inaccurate documentation of advance directives. Additionally, a medication order contained an incorrect hold parameter, and urine output was not properly documented after catheter removal for two residents. These issues were confirmed by interviews with nursing staff and the DON, who acknowledged the documentation errors.
Missed Shower Care, Documentation, and Care Planning
Penalty
Summary
The facility failed to provide necessary ADL care for three residents who were scheduled for showers and had repeated refusals documented in their records. Facility policy stated that residents who refuse care should be informed and educated about the risks and benefits, offered alternatives, and that the comprehensive care plan should include services not provided because of the resident’s right to refuse treatment. For Resident 1, who had moderate cognitive impairment and was observed awake, oriented to person, and forgetful, the record showed multiple shower refusals and no documentation of interventions, care plan development, or notification of the responsible party related to those refusals. Resident 2 had severe cognitive impairment and was observed sitting up in bed, awake, oriented to person, and forgetful, with rashes noted on the back and a topical steroid ordered for the rash. The record showed shower refusals on multiple scheduled shower days, and the medical record did not contain documentation of interventions, a care plan, or notification of the responsible party related to the refusals. The record also failed to show a shower skin inspection sheet for one scheduled shower, and the assigned nurse confirmed that CNAs were responsible for completing the shower skin inspection sheet after each shower and reporting skin observations or refusals to the LVN. Resident 3 had no capacity to understand and make decisions and had a topical steroid ordered for a rash on the right upper chest. The shower binder for Nurse Station A was missing multiple shower skin inspection sheets for this resident on several scheduled shower dates. The DSD stated that CNAs were required to complete the shower skin inspection sheets after showers, document refusals on the sheet if a resident refused, and notify the licensed nurse, and that missing sheets indicated they were not completed. The ADON stated that after two refusals in a month of resident care, including showering or bathing, licensed nurses were to offer alternatives, educate the resident about risks and benefits, notify the physician and responsible party, complete change-of-condition documentation, and develop a care plan.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure residents or their representatives were fully informed in advance of proposed psychotropic medication treatment for multiple residents. The report states that informed consent forms for several psychotropic medications did not contain required information such as the indication for use, duration of use, diagnosis, or behavior manifestation, and in one case the consent obtained by telephone was not verified by two licensed nurses as required by facility policy. For Resident 6, who had no capacity to understand or make decisions, the record showed buspirone was administered for anxiety manifested by physical restlessness and trazodone was administered for depression manifested by inability to sleep. The informed consent form for trazodone did not document the duration of use or the indication for use, and the informed consent form for buspirone did not document the duration of use. The record also showed an order for PRN lorazepam for anxiety manifested by yelling out for 14 days, but the chart did not show that informed consent was obtained for that PRN medication. For Resident 10, who was documented as having capacity to understand and make decisions, the informed consent form for paroxetine listed depression but did not include the behavior manifestation of verbalization of sadness, and the informed consent form for trazodone listed insomnia but did not show the correct diagnosis and behavior manifestation of inability to sleep. For Resident 13, the informed consent form for Ativan listed anxiety but did not include the behavior manifestation of verbalization of feeling anxious. For Resident 214, the informed consent form for trazodone included inability to sleep but did not include the diagnosis. For Resident 238, the informed consent for olanzapine was given by the resident's representative via telephone, but only one licensed nurse verified the consent instead of two.
Unsafe Environment and Missing Property Not Properly Addressed
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents in Rooms A and B. In Room A, Resident 5 was observed with a closet door in disrepair, including chipped and peeled paint and a missing bottom left corner, and the wall behind Resident 26’s bed had chipped paint. Resident 5 was cognitively intact, and Resident 26 had no capacity to understand and make medical decisions. In Room B, Resident 6 was observed with multiple areas of chipped and peeled paint on the wall between the bed and bedside drawer, the bedside drawer edges were chipped, and the wall behind Resident 171’s bed also had chipped and peeling paint. Resident 6 lacked capacity for medical decision-making, and Resident 171 could make needs known but could not make medical decisions. The ADON and DON acknowledged that the residents should be provided a homelike environment and verified the observations. The facility also failed to protect and investigate missing personal property for Resident 14. Resident 14 reported that a heart monitor, a mattress he had purchased, tennis shoes, a back brace, and money were missing or misplaced after a hospital transfer. Staff stated they were aware of the missing mattress and that it had been delivered back on readmission, but there was no documented evidence of an investigation for the mattress. A Theft and Loss Report existed for the heart monitor, but follow-up with Medtronic was not completed, and staff were not aware of or had not documented reports for the missing tennis shoes, back brace, or money.
Psychotropic Medication Monitoring and Documentation Failures
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications and failed to follow ordered monitoring parameters for several residents receiving psychotropic or related medications. The report states that the facility did not document required behavior monitoring for Resident 3 while quetiapine fumarate, fluphenazine, and sertraline were administered, and it also did not document that nonpharmacological interventions were provided before sertraline was given. Resident 3’s record showed a history of schizophrenia with hallucinations and delusions and depression with feeling sad, and the physician’s orders required monitoring of those behaviors every shift. For Resident 15, the record showed orders for olanzapine for schizophrenia bipolar type and a physician-ordered list of nonpharmacological approaches to attempt before administration. The MAR showed multiple administrations of olanzapine, but the monitoring record showed the nonpharmacological intervention section marked with 0 for those administrations. The ADON verified that the code could mean no nonpharmacological interventions were provided before the medication was given. The facility also failed to complete ordered monitoring for other residents receiving psychotropic medications. Resident 214 received trazodone for insomnia, with orders to monitor hours of sleep and inability to sleep every evening and night shift, but the monitoring record did not show those observations on the documented date. Resident 212 received escitalopram for depression and had an order to monitor for side effects such as dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypertension, dark urine, yellow skin, nausea and vomiting, lethargy, and drooling every shift, but several shifts in May lacked documentation. Resident 152, who had no capacity to make decisions and was receiving Risperdal, had orders for orthostatic BP monitoring while lying and sitting weekly, but the MAR showed identical BP readings for both positions on multiple Fridays, and the DON acknowledged the readings were not accurate because lying and sitting values would be expected to differ.
Care plans not revised to match current orders and resident status
Penalty
Summary
The facility failed to revise the comprehensive care plan for four sampled residents after comprehensive assessment and interdisciplinary review. The report states that the care plan was to be prepared, reviewed, and revised by a team of health professionals, and that the comprehensive care plan should describe resident-specific interventions reflecting each resident’s needs. Surveyors found that the care plans for Residents 10, 80, 174, and 238 were not updated to match current orders, conditions, or behavior manifestations documented in the medical record. For Resident 10, the physician ordered hydrocodone-acetaminophen 5-325 mg every six hours as needed for pain rated 5-10, with nonpharmacological interventions listed in the order, including relaxation, redirect/reapproach, repositioning, heat/cold therapy, gentle massage, and distraction. The care plan for pain and pain medication, revised on 4/28/26, did not include those nonpharmacological interventions. ADON 1 reviewed the record with surveyors and verified that the care plan was not updated to show or include the nonpharmacological interventions to be used before administering the pain medication. For Resident 80, an oxygen concentrator was observed at the bedside delivering continuous oxygen at 4 liters per minute, but the care plan intervention for oxygen use was not specific to the resident’s current oxygen amount. For Resident 174, the physician’s order was for a fluid restriction of 1200 ml per day, but the care plan intervention still reflected a fluid restriction of 1000 ml per day. For Resident 238, the physician ordered mirtazapine 15 mg via PEG tube at bedtime for depression as manifested by sad affect, but the care plan problem and intervention still described the medication use as manifested by poor oral intake and included meal intake monitoring. RN 1, RN 4, and the DON were each informed during interviews and acknowledged the findings.
Failure to Rotate Insulin Injection Sites and Monitor Weight Loss
Penalty
Summary
The facility failed to ensure insulin injection sites were rotated for two residents with diabetes mellitus. Resident 6 was admitted with type 2 DM and had physician orders for lispro insulin before meals and at bedtime per sliding scale, as well as insulin glargine at bedtime with instructions to rotate injection sites. Review of the May 2026 MAR showed repeated administration of insulin glargine at the left lower quadrant of the abdomen on multiple dates, and lispro insulin was also documented at the left lower quadrant on two dates. During interview and record review, an LVN verified the findings and stated the injection site should be rotated. Resident 11 was admitted and later readmitted, and had physician orders for regular human insulin every six hours per sliding scale and insulin glargine at bedtime. Review of the May 2026 MAR showed insulin glargine was repeatedly administered at the left lower quadrant of the abdomen on multiple dates, and regular human insulin was also documented at the left lower quadrant on several dates and times. The LVN reviewed the MAR and verified the repeated use of the same injection site. The facility also failed to continuously monitor Resident 15 after a change in condition related to weight loss. Resident 15 had decision-making capacity, and an eInteract change-in-condition evaluation documented a 7-pound weight loss in one month, with the physician notified and the RD aware. The care plan was revised to address unplanned weight loss and included monitoring and evaluating the weight loss, but the progress notes from 5/7/26 through 5/10/26 did not show documented continued monitoring related to the weight loss. The ADON verified that Resident 15 was not monitored continuously related to the unplanned weight loss.
Failure to Monitor Weight Loss and Fluid Restriction
Penalty
Summary
The facility failed to ensure that residents with nutritional concerns were appropriately monitored and managed when significant weight loss and poor oral intake occurred. One resident with a diagnosis of severe protein-calorie malnutrition had documented poor PO intake throughout March, including multiple meals at 0% to 50% intake and several refused meals or substitutes, yet there was no documented response to address the poor intake during that month. The resident’s weight dropped from 145 lbs. to 121 lbs., a loss of 24 lbs., and later to 117 lbs., but the record did not show that the physician was informed of the 24-lb. loss, that the RD reassessed the resident in a timely manner, or that the IDT reviewed the weight variance when the severe loss was identified. The same resident’s nutritional documentation also showed inconsistent baseline weights and incomplete care planning. The RD assessment dated 3/29/26 documented the resident as refusing weights for three months and recommended increased snacks, but the record did not show that the resident’s poor intake in March was addressed at that time. After the resident’s weight loss was identified on 4/1/26, the change in condition evaluation documented poor PO intake and monitoring recommendations, but it did not document the current weight loss of 24 lbs. from the prior recorded weight. The resident’s care plan also did not include specific interventions or monitoring related to the meal refusal and weight loss that had been documented. A second resident had a 7-lb. weight loss in one month, and the RD recommended snacks twice daily and weekly weights for two weeks, but the record did not show that the weekly weights were monitored as recommended. The RD’s recommendation was not communicated and carried out until weeks later, and the clinical recommendation form did not show the weight-loss concern when first identified. A third resident had a physician’s order for a 2000 ml/24-hour fluid restriction, but staff placed a full water pitcher at the bedside and the record did not show documentation of the dietary portion of the fluid restriction. The monitor record showed nursing fluid totals that exceeded the ordered restriction on multiple dates, and staff acknowledged that the dietary intake was not documented in the resident’s fluid totals.
Incomplete GT Feedings and Water Flushes
Penalty
Summary
The facility failed to provide the ordered GT enteral feedings and water flushes for four sampled residents who were receiving tube feedings. The report states that Residents 6, 11, 130, and 238 did not receive the complete prescribed amounts of enteral formula and water flushes as ordered by the physician. The facility’s policy required residents receiving enteral nutrition to maintain acceptable nutritional and hydration status and to receive appropriate treatment and services related to enteral feeding. Resident 6 was observed in bed with a feeding pump hanging on the pole, but no enteral feeding formula was observed. The physician’s order called for continuous Glucerna 1.5 at 55 ml per hour for 20 hours to provide 1100 ml, along with continuous water flushing at 50 ml per hour for 20 hours to provide 1000 ml. When the pump history was checked, it showed 1002 ml fed and 900 ml flushed, and the RN verified the resident did not receive the full ordered amounts. Resident 11 was also observed in bed with no enteral feeding being administered, despite orders for Glucerna 1.5 at 55 ml per hour for 20 hours to provide 1100 ml and water flushes at 25 ml per hour for 20 hours to provide 500 ml. The pump history showed 1024 ml fed and 450 ml flushed, and the RN verified the resident did not receive the full ordered amounts. Resident 130, who had dysphagia, no capacity to understand and make medical decisions, and a feeding tube, was ordered Fibersource HN at 40 ml per hour for 20 hours to provide 800 ml and water at 20 ml per hour for 20 hours to provide 400 ml, but the pump history showed 73 ml left and 37 ml flushed; the RD recommendation to increase the feeding to 50 ml per hour for 20 hours was not followed up with the physician. Resident 238 was ordered Fibersource at 80 ml per hour for 20 hours to provide 1000 ml and water at 24 ml per hour for 20 hours to provide 480 ml, but the pump history showed 967 ml fed and 456 ml flushed, and the RN verified the resident did not receive the full ordered amounts.
Failure to Provide and Document Pain Management Interventions
Penalty
Summary
The facility failed to provide necessary pain management care and services for four residents who required pain treatment. The report states that for Residents 3 and 214, the medical record did not show documented nonpharmacological interventions before PRN pain medication was administered. Resident 3 had a right below-the-knee amputation, reported constant right leg pain, and had an order for hydrocodone-acetaminophen 5-325 mg every 6 hours as needed for pain rated 5-7. Resident 214 was alert, verbal, and oriented times three, reported right shoulder pain rated about 5, and had an order for tramadol 50 mg every 8 hours as needed for moderate to severe pain. For Resident 22, the physician ordered hydrocodone-acetaminophen 5-325 mg every 4 hours as needed for severe pain rated 8-10, but the MAR showed the medication was given when the documented pain level was 6 on two occasions. The ADON verified that the medication should not have been given for a pain level of 6 because it was outside the ordered parameters. The DON stated she expected licensed nurses to accurately document the resident’s pain level and give pain medication as ordered. For Resident 152, the physician ordered acetaminophen 325 mg, two tablets every 4 hours as needed for pain rated 1-4, but the MAR showed the medication was given when the resident’s pain level was 9. Resident 152 had no capacity to understand and make decisions. The ADON verified that a pain level of 9 was severe pain, that the resident did not have a medication ordered for severe pain, and that no nonpharmacological interventions were documented before the medication was administered.
Dialysis Care and Fluid Monitoring Deficiencies
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for three residents receiving hemodialysis. The report states that the facility did not accurately monitor fluid intake for two residents, did not consistently monitor hemodialysis access sites for bruit, thrill, redness, swelling, bleeding, or pain, and did not document notification to the physician, dialysis facility, or nephrologist when access concerns were identified. The facility also failed to monitor one resident for extra fluids at the bedside and kept an emergency dialysis access kit in the room that did not match the resident’s access type. For one resident with a left forearm AVF and a 1200 ml fluid restriction, the record showed inconsistent fluid documentation between CNA meal documentation and the licensed nurses’ Monitor Record. The CNA documentation included multiple entries that were higher than, or not reflected in, the nursing totals, and some meal periods had no documentation. The same resident’s access monitoring was also inconsistent, with entries of N or no documentation for bruit and thrill on some shifts, and repeated documentation of pain at the access site on many shifts. The record did not show notification to the attending physician, dialysis facility, or nephrologist regarding the fluid intake concerns, absent bruit and thrill, or ongoing pain. For a second resident with a left forearm AV shunt and a 1000 ml fluid restriction, the Monitor Record showed a total fluid intake of 1040 ml on one day. The access monitoring again showed entries of N, 0, or no documentation for bruit and thrill on multiple shifts, along with repeated documentation of pain at the access site. The record did not show notification to the attending physician, dialysis facility, or nephrologist regarding the fluid intake, access findings, or pain. The DON stated she did not know why staff documented 0 or N for bruit and thrill and stated nursing interventions should have been done when the resident complained of pain. For a third resident with a left chest Permacath and a 1200 ml fluid restriction, staff observed a half-consumed bottle of soda and a cup of water at the bedside. The resident’s record did not show CNA documentation of fluid intake under Task. The resident also had a transparent bag in the room labeled as a dialysis torniquet kit, but LVN staff verified it contained supplies such as a blue torniquet and did not contain plastic clamps, and stated the torniquet would not be appropriate for a resident with a Permacath. The DON was informed and acknowledged the findings.
Kitchen Staff Failed to Demonstrate Proper Ware Washing, Sanitizer Testing, and Hand Hygiene
Penalty
Summary
The facility failed to ensure kitchen employees had the appropriate competencies and skill sets to carry out food and nutrition services functions. During observation, two dietary aides did not follow proper manual ware washing procedures when cleaning utensils and pans at the two-compartment sink. One dietary aide scrubbed soiled pans in the first compartment, then rinsed them with the faucet water running back into the same compartment before placing them in the sanitizing solution. Another dietary aide cut cantaloupes, then took two knives to the ware washing station, rinsed them with the faucet without washing them in the first compartment, and placed them in a clean knife holder in dry storage. The facility also failed to show that one cook could accurately check sanitizer concentration. The cook tested the sanitizer used for food preparation surfaces by dipping the test strip into the solution for six seconds, then removed it, looked at it, put it back into the solution, stirred it, and stated the sanitizer was less than 200 ppm without comparing the strip to the color chart on the container. Manufacturer instructions for the test paper indicated it should be held motionless in the solution for ten seconds and read immediately. In addition, two kitchen employees did not perform proper hand hygiene during food service tasks. One dietary aide removed gloves after manually washing pans, rinsed her hands over the sink compartment, and then handled clean pans without performing hand hygiene. A cook thawing raw chicken in a sink touched the raw chicken and then his hat with gloved hands, removed his gloves, donned a new pair, and did not perform hand hygiene before continuing. The LRD and Administrator were informed of the findings, and the LRD stated there was no evidence of in-service training on manual ware washing, sanitizer testing, or hand washing for food service staff in the past year.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
Food safety and sanitation practices were not followed in the kitchen during multiple observations and interviews. The facility did not monitor the cooling process for time/temperature control for safety foods. Egg salad, tuna salad, and ham salad were observed in the walk-in refrigerator with temperatures above safe refrigeration levels over several observations, and the Dietary Manager stated there was no cool down log available for the salads even though the salads had been prepared in the facility kitchen that morning. Hand hygiene was not performed correctly by kitchen staff during food service activities. One dietary aide washed and sanitized pans in a two-compartment sink, removed gloves, rinsed hands over the sink, and then picked up clean dish pans without performing hand hygiene. Another kitchen employee, while thawing raw chicken in a sink, touched the raw chicken and then touched his hat with gloved hands, removed the gloves, put on a new pair, and did not perform hand hygiene before continuing. The facility also did not follow its thawing, ware washing, storage, and equipment sanitation practices. Thirty pounds of tilapia and five pounds of diced beef were thawing in the walk-in refrigerator without labels showing the pull date or cook date. A two-compartment manual ware washing sink was used in a way that allowed rinse water to run into the wash compartment, and the facility’s policy did not specify proper use of the sink. Clean utensils were stored in uncovered bins that had dried food debris, and some stored scoops were soiled. The Dietary Manager was observed without a beard restraint, wet food service equipment was stored without air drying, five green cutting boards were heavily marred and one was soiled, and two can opener blades were worn and not clean.
Unsafe Handling of Outside Food Brought for Residents
Penalty
Summary
The facility failed to ensure safe food handling of food brought in for residents from outside sources. The report states the facility had a policy regarding the use and storage of foods brought to residents by family and other visitors, and CMS guidance was reviewed showing residents may choose to accept food from visitors, family, friends, or other guests, while the facility is responsible for helping visitors understand safe food handling practices, including not holding or transporting perishable foods above 41 degrees Fahrenheit. During observation in the dining room, a designated resident food refrigerator was seen, and RN 2 stated residents and family were allowed to bring outside food that was stored in the resident refrigerator. When asked about education provided to residents and families, RN 2 stated the facility instructed them that food brought from home could be stored in the refrigerator for 72 hours before being discarded, but did not describe education on food temperature control, transport, or other safe handling practices. The DON later stated residents and families were allowed to bring in outside food and that uneaten food would be discarded after two hours if not consumed; the DON also stated education was limited to manufactured food being discarded 72 hours after open date and unopened manufactured food being kept until expiration date, and verified residents and families did not receive education on safe food handling practices such as temperature control, transport, and prevention of foodborne illness.
Facility Assessment Missing Required Staffing and Participation Elements
Penalty
Summary
The facility failed to ensure its Facility Assessment addressed required elements for resident care and staffing. Based on interview and facility document review, the assessment did not show active involvement of direct care staff, direct care representatives, residents, residents' representatives, or residents' family members in developing the Facility Assessment. It also did not include a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. Review of the Facility Assessment dated 10/21/25 showed these omissions, and on 6/3/26 at 1622 hours, the Administrator was interviewed with concurrent document review. The Administrator verified that the Facility Assessment did not include active involvement from the required individuals and did not contain documentation of a recruitment and retention plan or a contingency staffing plan. The Administrator stated she was not aware of the current CMS guidance and verified that the Facility Assessment had not been updated based on the latest CMS guidance.
Inaccurate infection surveillance and incomplete use of infection criteria
Penalty
Summary
The facility failed to implement its infection prevention and control program in accordance with its policies and procedures. The infection preventionist was responsible for surveillance and tracking infections, but the monthly infection surveillance reports from January 2026 through May 2026 were not accurate. The facility’s surveillance was based solely on whether residents were prescribed antimicrobial medications, and residents who had signs and/or symptoms of infection but were not prescribed antimicrobials were not included in the surveillance report or evaluated using McGeer criteria. The facility’s Infection Surveillance Reports did not match the infection logs for multiple months, and the infection preventionist confirmed that all residents listed in the reports had been prescribed antimicrobials. Review of the facility’s records showed that residents with signs and symptoms of infection were not consistently evaluated to determine whether they met the facility’s criteria for a true infection. The infection preventionist stated McGeer criteria were only used for residents who were prescribed antimicrobial therapy, and the monthly surveillance reports included only those residents. Review of the records for Residents 21, 37, 55, 104, 243, 244, 245, 246, and 247 showed that the infection classifications documented in surveillance were incorrect. Examples included residents documented as having urinary tract infections, sepsis, pneumonia, respiratory infection, or C. difficile despite missing required supporting findings such as urine culture results, chest radiograph findings, stool testing, or other criteria required by the surveillance definitions. The infection preventionist reviewed these records and verified that the classification of these residents’ infections as true infections was incorrect. The DON also stated that residents with signs and/or symptoms of infection who were not prescribed antimicrobials should have been included in the monthly infection surveillance report.
Failure to Monitor Antibiotic Use and Complete Required Infection Review
Penalty
Summary
The facility failed to accurately monitor and address antibiotic use for one sampled resident and nine nonsampled residents reviewed for antibiotic stewardship. The report states that the facility did not ensure the Infection Screening Evaluation and Antibiotic Time Out were completed when a resident was prescribed azithromycin 500 mg IV daily for five days. The resident had fluctuating capacity, and the medical record did not show documented evidence that the infection was screened or that the antibiotic was reviewed to determine whether the infection met criteria for a true infection. The facility’s Infection Preventionist stated that licensed nurses were responsible for initiating the infection screening evaluation when residents showed signs and symptoms of infection, and that the Infection Preventionist was responsible for initiating the Antibiotic Time Out within 72 hours of antibiotic prescribing. The Infection Preventionist also stated that if the infection did not meet McGeer’s criteria, the physician would be notified that the antimicrobial therapy may not be appropriate. Review of the resident’s record confirmed that this process was not documented for the sampled resident. For nine additional residents, review of the Antibiotic Time Out forms showed that their infections did not meet McGeer’s criteria for a true infection, yet each resident was prescribed antimicrobial therapy, and the forms did not indicate DNMC. The DON was informed of these findings during interview. The facility’s monthly infection surveillance reports also showed ongoing infection activity across the reviewed months, including HAIs and CAIs, while the antibiotic stewardship records reflected that some residents received antimicrobial therapy despite not meeting the facility’s surveillance criteria for infection.
Pneumococcal Vaccine Consent and Documentation Deficiencies
Penalty
Summary
The facility failed to offer and provide education for pneumococcal immunizations for three of five sampled residents reviewed for immunizations. The facility’s policy stated that each resident would be offered a pneumococcal immunization unless medically contraindicated or already immunized, and that the resident or representative would receive education regarding benefits and potential side effects before the vaccine was given. The policy also stated that a consent form would be signed prior to administration and that the type of pneumococcal vaccine offered would depend on the resident’s age and susceptibility to pneumonia in accordance with CDC guidelines. Resident 5 was cognitively intact and signed a consent form indicating consent for the pneumococcal 21 vaccine, but the MAR showed that the resident received the Pneumococcal 20-Valent Conjugate Vaccine instead. Resident 11 had severely impaired cognitive skills for daily decision making, and Resident 69 had no capacity to understand and make decisions; both had representative-signed consent forms that stated education had been provided, but the section identifying the kind of pneumococcal vaccine to be given was left blank. Their MARs showed both residents received the Pneumococcal 20-Valent Conjugate Vaccine. During interview and record review, the IP verified that the consents for Residents 11 and 69 did not identify the vaccine type and stated the consents should have indicated the type of vaccine received so the residents and representatives would be fully informed. The IP also verified that Resident 5 did not receive the vaccination consented to by the resident’s representative, and the DON acknowledged the findings.
Ice Machine and Ice Bin Not Sanitized per Manufacturer Instructions
Penalty
Summary
The facility failed to maintain the ice machine and ice storage bin in safe operating condition when the manufacturer’s sanitizing instructions were not followed. Review of the Scotsman Ice Systems model C1030 guidelines showed that sanitizing required a locally approved sanitizer mixed with clean, warm water and circulated through the machine, and that the ice storage bin required a sanitizer solution to thoroughly wash all interior surfaces. The report stated that the ice machine was cleaned monthly, but the Maintenance Director described using Scotsman Clear 1 Scale Remover mixed with water for both cleaning and sanitizing the ice machine and the ice storage bin. During interview, the Maintenance Director stated he believed Scotsman Clear 1 was to be used for both cleaning and sanitizing. After the manufacturer guidelines were reviewed with him, he verified that the ice machine and ice storage bin were not being sanitized according to the manufacturer’s instructions. The LRD and Administrator were later informed of and acknowledged these findings.
Failure to Verify Safe Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to determine whether two residents were safe to self-administer medications that were left at the bedside. For one resident, a bottle of vitamin C was observed on a shelf in the room, and the resident did not respond when asked about self-administration. For the other resident, five vials of refresh eye drops were observed on the overbed table while the resident was lying in bed. For the resident with vitamin C, the medical record showed a physician order for ascorbic acid 500 mg twice daily, but there was no physician order authorizing self-administration of the medication. The resident’s Self-Administration of Medication assessment dated 4/2/24 stated the resident was not capable of safely self-administering medications. The plan of care also did not include a problem addressing self-administration or bedside storage of the medication. The resident stated the family had brought the vitamin C to the facility. For the resident with refresh eye drops, the medical record showed a quarterly MDS with a BIMS score of 12, indicating moderate cognitive impairment. The record did not contain a physician order for self-administration, an assessment for safe self-administration, or a care plan problem related to self-administration. During interview, the resident stated she was putting the eyedrops in her eye but could not remember how often she used them. The ADON verified the five vials were at the bedside and confirmed there was no order, assessment, or care plan for self-administration.
Failure to Notify Physician and Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to ensure the physician and the resident’s responsible party were notified of a significant change in condition for one resident reviewed for nutrition. The resident was admitted with a diagnosis of unspecified severe protein-calorie malnutrition and had fluctuating capacity noted in the H&P. Weight records showed the resident weighed 149 lbs. on 11/19/25, 145 lbs. on 12/2/25, and 121 lbs. on 4/1/26, reflecting a 24 lb. loss from 12/2/25 to 4/1/26 and a severe overall weight loss. The resident’s E-interact Change in Condition Evaluation documented poor PO intake with less than 50% intake at the last three meals and noted the physician was notified of poor intake, with recommendations to monitor, encourage intake, assist with meals, and offer supplements. However, the Change in Condition Evaluation did not document that the physician was informed of the resident’s current weight of 121 lbs. or the 24 lb. weight loss from 12/2/25 to 4/1/26. During interviews, the ADON stated that weight variances meeting significant loss thresholds required physician notification and a change in condition evaluation, and the DON stated the unit manager/desk nurse was responsible for reviewing weights, initiating the evaluation, informing the physician and responsible party, and notifying the RD when significant weight loss was identified. The DON later verified there was no documentation that the physician or responsible party were informed of the resident’s 24 lb. weight loss.
Inaccurate MDS Coding for Weight Loss and Medications
Penalty
Summary
The facility failed to ensure MDS assessments were accurately coded for three sampled residents. For Resident 1, who had a diagnosis of unspecified severe protein-calorie malnutrition, the MDS did not reflect the resident’s documented weight loss of 5% in one month or 10% in six months. The weight record showed a decline from 149 lbs. on 11/19/25 to 116 lbs. on 5/19/26, and the Lead Registered Dietician verified that the resident had lost more than 10% in six months and that the MDS coding in Section K was inaccurate. For Resident 11, the MDS did not code the use of hypoglycemic medication, including insulin, despite physician orders for regular human insulin and insulin glargine for diabetes mellitus. The same MDS also coded the resident for anticonvulsant use even though no anticonvulsant medication was prescribed. For Resident 183, the quarterly MDS did not code injections even though the resident received enoxaparin 40 mg subcutaneously daily for DVT prophylaxis, with MAR documentation showing administration over several days. The MDS Coordinator and MDS Assistant Coordinator verified the inaccurate coding for these residents during record review.
Missing Care Plan for Hearing Impairment
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident 4 that addressed impaired communication related to bilateral hard of hearing and the use of bilateral hearing aids. The facility's policy required a comprehensive care plan within 7 days after completion of the comprehensive MDS assessment, including measurable objectives, timeframes, and resident-specific interventions for identified needs. Resident 4's H&P showed the resident had the capacity to understand and make medical decisions, and the MDS assessment indicated hearing difficulty and that hearing aids were used. During the initial tour, Resident 4 was observed awake and lying in bed and told the surveyor to speak louder near the left ear because he could not hear clearly. The resident also stated he had hearing aids, but they were broken and not being fixed. LVN 2 confirmed the resident was hard of hearing, used bilateral hearing aids, and that one hearing aid was broken, with the issue reportedly shared with the social worker about a week earlier. LVN 2 verified there was no care plan developed to address the resident's impaired communication related to hearing loss and hearing aid use, and the DON acknowledged the findings.
LAL Mattress Not Set According to Resident Weight
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for one sampled resident who was at risk for pressure injuries. Resident 10 was readmitted to the facility with a history of a healed stage 3 sacral pressure injury and was assessed as at risk for developing pressure ulcers, including a Braden Scale score of 15. A physician’s order was in place for a low air loss (LAL) mattress for skin management and comfort care every shift. During observations, Resident 10 was found lying in bed with the LAL mattress set in static mode and with no light showing for the comfort setting. This was observed during the initial tour and again during later observations while the resident was awake or sleeping in bed. The resident stated that nurses managed the bed and that she did not know how to operate the machine attached to the bed. The facility’s records and staff interviews showed the mattress setting was not aligned with the resident’s weight of 142 lbs. and that the comfort setting should have displayed a light based on the resident’s weight even when the mattress was in static mode. LVN 3 stated the mattress was being used for preventive purposes, that the comfort setting should be based on the resident’s weight, and verified that the mattress was in static mode with no light in the comfort setting. The DON was informed and acknowledged the findings.
Respiratory Care Not Provided in Accordance With Orders and Facility Policy
Penalty
Summary
The facility failed to provide respiratory services in a safe and sanitary manner for one of three sampled residents reviewed for respiratory care. Resident 80 was admitted and later readmitted to the facility, and the medical record review showed a history of pneumonia and that the resident had the capacity to understand and make medical decisions. On observation, the resident was lying in bed with an oxygen concentrator set to deliver continuous oxygen at 4 liters per minute. The oxygen tubing and nasal cannula were observed attached to the concentrator without a labeled date showing when they were changed, and there was no "Oxygen In Use" sign posted outside the resident's room. During interview and record review, RN 1 verified the resident was receiving continuous oxygen but did not have a physician's order for the oxygen therapy. RN 1 also confirmed the tubing was not labeled and the required signage was not posted. The DON later verified these findings and stated that a physician's order was required for oxygen therapy and that an oxygen sign should be posted outside the room.
Improper Administration of Delayed-Release Medication and Nebulizer Treatment
Penalty
Summary
Safe and effective pharmaceutical services were not provided for Resident 152 when RN 8 crushed and administered Depakote 125 mg delayed-release tablet that had been ordered twice daily. The facility’s medication administration policy required medications to be given as ordered and in accordance with manufacturer specifications, and the medication leaflet for Depakote stated not to chew, break, or crush the medication. During a medication pass observation, RN 8 was observed crushing the Depakote DR tablet and giving it to the resident. RN 8 later verified the medication had been crushed and stated she was not trained on what DR meant for the Depakote medication. The DON stated nurses could not assume all medications were crushable, and the consultant pharmacist stated Depakote should not be crushed. Safe and effective pharmaceutical services were also not provided for Resident 110 when arformoterol nebulization solution was administered at 1200 hours instead of in the morning as required by the manufacturer’s prescribing information. The resident had an order for arformoterol inhalation via nebulizer twice daily for COPD, and the H&P noted the resident had been readmitted after being sent out for evaluation of shortness of breath. The MAR showed the treatment was scheduled for 1200 hours and 2100 hours, and the medication was administered at 1200 hours on the observed date. LVN 4 stated the treatment was given at 1200 hours but verified it was supposed to be given in the morning. The resident stated they had trouble breathing and that nebulizer breathing treatments were the only thing that helped.
Pharmacist Review Failed to Identify and Report Medication Irregularities
Penalty
Summary
The facility failed to ensure the consultant pharmacist identified and reported all irregularities during the monthly medication regimen review for two residents. For one resident with COPD, the order summary showed roflumilast 250 mcg by mouth daily, and the consultant pharmacist later verified the manufacturer’s dosing instructions that the maintenance dose is 500 mcg daily and that 250 mcg daily is not the effective therapeutic dose. The consultant pharmacist also verified that no recommendation about the roflumilast dose appeared in the medication regimen review reports. For another resident, the consultant pharmacist’s medication regimen review noted that the physician should be made aware that systolic blood pressure readings had been consistently high, regularly above 140 mmHg, and that changes in antihypertensive therapy might be warranted. The review also included a handwritten note stating nurses were in-serviced. During record review and interview, the DON could not show documented evidence that the physician had been informed of the consultant pharmacist’s recommendation, and the DON verified the recommendation was not acted upon.
Failure to Follow Medication Hold Parameters and Monitor Potassium Levels
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when it did not follow physician orders to hold atenolol and benazepril if the resident’s pulse rate was below 70 beats per minute. Resident 113 had a quarterly MDS showing a BIMS summary score of 12, indicating moderately impaired cognition. The resident’s MAR showed orders for atenolol 25 mg daily, to be held if systolic blood pressure was below 110 or pulse rate was below 70, and benazepril 40 mg daily with the same hold parameters. Review of the MAR for May and June 2026 showed atenolol was administered on multiple dates when the resident’s pulse rate was below 70 beats per minute, including readings of 60, 68, 66, 64, 62, and 61 beats per minute. The same review showed benazepril was also administered on multiple dates when the resident’s pulse rate was below 70 beats per minute, including readings of 68, 60, 55, 64, 62, and 61 beats per minute. During interview and record review, RN 8 stated that BP medications should be checked against the resident’s BP and pulse before administration and held if outside ordered parameters. The facility also failed to ensure potassium levels were closely monitored for Resident 110, who was receiving potassium chloride oral solution and lisinopril at the same time. The resident had orders for potassium chloride 20 mEq daily and lisinopril 5 mg daily. The facility could not locate additional potassium laboratory results in the medical record between 7/16/25 and 6/3/26, and the consultant pharmacist stated that giving potassium chloride with an ACE inhibitor could potentially increase potassium levels.
Unlabeled Medications in Medication Carts
Penalty
Summary
The facility failed to ensure safe medication labeling practices in accordance with accepted professional standards. During observation and interview, three opened bottles of artificial tears and one opened bottle of fluticasone nasal spray were found inside medication carts without resident-specific labeling. The facility's policy stated that medications and biologicals used in the facility would be labeled in accordance with current state and federal regulations to support safe administration. On Medication Cart A, an opened carton of fluticasone nasal spray was observed without a label identifying the resident, and an LVN verified it belonged to Resident 212. On Medication Cart B, three unlabeled bottles of artificial tears were observed, and an LVN verified they were for Residents 108, 109, and 195. During record review, there were physician's orders for artificial tears for Residents 108 and 195, but no medication order for Resident 109. Staff interviews confirmed the bottles and carton were supposed to be labeled with resident-specific information, and the DON stated that once a medication carton was opened, the multidose unit inside was expected to be labeled with the date and the name.
Dietary Manager Credential Lapse and Inadequate RD Oversight
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the education and credentialing requirements required by California Health and Safety Code 1265.4 and failed to ensure the Dietary Manager remained competent to manage the day-to-day functions of the food and nutrition department. The facility’s job description required the Dietary Supervisor to be a Certified Dietary Manager, and the facility’s matrix showed 187 residents consumed food prepared in the kitchen. During interview, the Dietary Manager stated he had worked at the facility for one to two months, had completed an online course from North Dakota, and was a CDM. He later showed a CDM certificate issued in 7/2020 and stated he renewed his certification a year ago but had not received a new certificate. He also stated he was not aware he was required to complete continuing education credits to keep his credentials current. Review of the ANFP website showed he was not registered as a Certified Dietary Manager, and the LRD later stated there was a lapse in his credential because he did not complete the required continuing education and was currently not a Certified Dietary Manager. The facility also failed to ensure adequate oversight of the food and nutrition department by the RD. The RD job description stated the RD provides oversight and guidance to the Dining Services Director regarding dining services operations. However, during the annual recertification survey, multiple kitchen issues were observed, including lack of a cool down process for time/temperature control for safety food, improper hand hygiene, failure to follow the thawing process for meats, improper manual ware washing, utensils and equipment not clean or stored in a sanitary manner, hair restraints not worn, food service equipment not air dried, and multiple cutting boards that were heavily marred and not clean. These findings were acknowledged by the LRD and Administrator during interview. The RD’s monthly Quality Assurance Evaluations for dining dated 3/17, 4/15, and 5/13/26 documented satisfactory performance in areas that were later found deficient during survey, including hair and beard coverage, thawing foods, equipment cleanliness, cooling procedures, dish machine and 3-compartment sink temperatures and chemical ppm, dishware and utensil storage, handwashing, and manager qualification status. During interview, the LRD stated the RD was on vacation and she was covering the position temporarily. The LRD acknowledged that the survey findings were scored as satisfactory on the RD’s evaluations for the prior three months.
Incomplete COVID-19 Vaccine Consent Documentation
Penalty
Summary
The facility failed to ensure that the informed consent for Resident 11’s COVID-19 vaccination specified the type of COVID-19 vaccine to be administered. Resident 11 was admitted to the facility and later readmitted, and the MDS showed severely impaired cognitive skills for daily decision-making. The resident’s representative electronically signed a COVID-19 Vaccine Consent Form and consented to vaccination, but the section identifying the brand of COVID-19 vaccine was left blank. The facility’s policy stated that recipients should be informed that Moderna, Novavax, and Pfizer-BioNTech COVID-19 vaccines are recommended and that residents or their representatives should be educated regarding the risks, benefits, and potential side effects before the vaccine is offered. Resident 11’s MAR showed administration of Spikevax (Moderna COVID-19 vaccine), but the consent form did not identify the vaccine brand. During interview and record review, the IP verified the consent form did not indicate the type of vaccine given, and the DON was informed and acknowledged the finding.
Failure to Maintain Proper Catheter Care and Bag Placement
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received appropriate care and services as required by facility policy and CDC guidelines. During an observation, the resident's urinary drainage bag and tubing were found touching the floor, and the drainage bag was not placed inside a dignity bag as specified in the facility's catheter care policy. The policy requires catheter care to be performed every shift, with privacy bags available and drainage bags covered at all times. The CDC guideline also states that urine collection bags should not rest on the floor. The deficiency was confirmed through observation, staff interview, and review of the resident's medical record and facility policies. The LVN present acknowledged that the drainage bag and tubing should not be touching the floor and should be inside a dignity bag. The DON also verified the findings, noting that although the resident was on a low bed, there should have been a measure in place to prevent the drainage bag from contacting the floor. The resident had an order for an indwelling urinary catheter due to obstructive uropathy.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident with an indwelling urinary catheter. During an observation, the resident's urinary drainage bag and tubing were found touching the floor, and the drainage bag was not placed inside the required privacy (dignity) bag. This made the urine contents visible to anyone entering the resident's room. The facility's policy requires that catheter drainage bags be covered at all times with a privacy bag and that catheter care be performed every shift to ensure dignity and privacy for residents with indwelling catheters. A review of the resident's medical record showed an order for an indwelling urinary catheter due to obstructive uropathy. Staff interviews confirmed that the drainage bag and tubing were improperly positioned and not covered, contrary to facility policy and CDC guidelines. The Director of Nursing acknowledged the findings and verified that the drainage bag should not have been touching the floor and should have been inside a dignity bag.
Failure to Follow Contact Precautions for Resident with C. diff Infection
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident who was on contact precautions due to a C. diff infection. According to the facility's policy, staff are required to wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment, and to don personal protective equipment (PPE) upon room entry. During an observation, an Activity Assistant was seen inside the resident's room without wearing the required gown and gloves. When questioned, the Activity Assistant admitted to forgetting to check the signage at the door before entering. Additionally, the signage posted at the resident's door was not updated to reflect the current contact precautions required for C. diff infection. The Infection Preventionist (IP) confirmed that the signage should have indicated contact precautions and acknowledged the oversight. The resident had a physician's order for contact isolation due to C. diff, and the facility's policy specified the necessary infection control measures, which were not followed during the observed incident.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals served to residents.
Failure to Follow Prescribed Breakfast Menu for a Resident
Penalty
Summary
The facility failed to follow the prescribed breakfast menu for one resident who was on a no salt added regular portion diet. According to the menu, the resident was supposed to receive a Belgian waffle, breakfast meat of choice, seasonal fruit cup, and hot or cold cereal. However, the resident was only served two waffles and oatmeal, without the breakfast meat or seasonal fruit cup. The resident's meal ticket indicated a dislike for sausage and milk, but not all dairy products, and the resident stated she would have eaten eggs if they had been provided. The omission of the fruit cup was due to a late delivery, and the dietary manager acknowledged that they were unaware of the shortage until trayline service was underway. Residents were not informed about the missing items until they received their trays. Review of facility documents showed that the menus are required to meet the nutritional needs of residents and be followed as planned. The dietary manager and certified dietary manager confirmed that the menu was not followed for this resident, and the resident confirmed that she did not receive the full menu items for breakfast on that day. This failure had the potential to result in the resident not receiving adequate nutrition and appropriate servings to meet her individual needs.
Incomplete Medical Record and Missing Physician Order for Bolster Pillow
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete regarding the use of bilateral bolster pillows. The resident, who was unable to make medical decisions, had a care plan intervention for bilateral bolster pillows following an unwitnessed fall from bed. However, the medical record review revealed that the informed consent form for the bolster pillow was not signed by the provider who obtained the consent, and there was no physician's order for the use of the bolster pillow documented in the resident's records. During interviews and concurrent medical record reviews, both an LVN and the DON confirmed that a bolster pillow required both a signed consent from the resident or representative and a physician's order, neither of which were present in this case. The facility's policy on informed consent also specified that the healthcare professional proposing the intervention is responsible for providing information and obtaining proper consent, which was not followed in this instance.
Improper Colostomy Care Results in Resident Burn Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to provide necessary care and services to a resident with a colostomy, resulting in a burn injury. The CNA attempted to empty the resident's colostomy bag but was unable to remove all fecal matter. Instead of following facility policy and procedure, which prohibits direct care staff from putting fluids into the colostomy bag, the CNA left the room, obtained a cup of hot water, and poured it into the colostomy bag. During this process, the colostomy bag touched the resident's skin, causing a burning sensation and subsequent injury to the left thigh and abdomen. The resident, who was cognitively intact and able to make decisions, immediately reported pain and burning to the CNA, but the CNA did not promptly respond. The resident had to physically intervene to stop the procedure. The incident resulted in redness and, later, a blister on the resident's left thigh. The medical record documented the development of a burn wound, with measurements and a wound status of open, and the resident required pain medication and wound treatment as a result. Interviews with facility staff, including the CNA, LVN, DSD, and DON, confirmed that the CNA used hot water inappropriately and did not follow established protocols for colostomy care. Facility policy clearly states that CNAs are not permitted to put fluids into colostomy bags and should notify a supervisor if additional care is needed. The CNA admitted to not checking the water temperature and not using appropriate protective measures, such as a towel, which contributed to the resident's injury.
Nurse Aide Lacks Competency in Colostomy Care, Resulting in Resident Burn
Penalty
Summary
The facility failed to ensure that a nurse aide demonstrated competency in the skills and techniques necessary to care for a resident with a colostomy, as identified through the resident's assessment and care plan. The nurse aide, who had been employed for less than three months, was responsible for emptying a resident's colostomy bag but was not properly trained on the procedure during orientation or in CNA school. Instead, the aide learned from other CNAs, one of whom demonstrated pouring water into the colostomy bag, a practice not permitted by facility policy. During the incident, the nurse aide attempted to empty the colostomy bag but was unable to remove all fecal matter. The aide then left the room, obtained a cup of water from a dispenser, and poured it into the colostomy bag without checking the water temperature. The hot water came into contact with the resident's skin, causing a burning sensation and resulting in redness and a blister on the resident's left thigh and abdomen. The resident reported significant pain and had to alert the aide to stop the procedure. The aide acknowledged the error and reported the incident to a nurse, who observed the injury and provided pain medication. Facility policy and lesson plans explicitly state that direct care staff are not permitted to put fluids into a colostomy bag and should notify a supervisor if they encounter care needs beyond their scope. Interviews with facility leadership confirmed that the aide should not have performed the action and that the required competency for emptying an ostomy bag was documented as completed, despite the aide's lack of proper training. The incident resulted in a burn injury to the resident, with documentation of the wound and subsequent treatment.
Failure to Serve Lunch Meals at Scheduled Times Due to Kitchen Malfunction
Penalty
Summary
The facility failed to provide lunch meals to 196 out of 216 residents at the scheduled mealtime, as required by facility policy and posted meal schedules. On the day in question, the kitchen oven thermostat and igniter malfunctioned, causing the kitchen staff to begin plating lunches an hour late. As a result, the first lunch trays did not leave the kitchen until 1257 hours, well after the scheduled lunch period of 1130 to 1230 hours. The Dietary Manager confirmed that all residents receiving kitchen-prepared meals would not receive their lunch within the scheduled timeframe, which was important for those with medications scheduled around meal times. Multiple residents reported not receiving their lunch at the expected time, expressing feelings of hunger, frustration, and aggravation. One resident, who had received six units of insulin at 1130 hours, had not received her lunch by 1320 hours and reported feeling sweaty and hungry, requiring juice and a snack from staff. Nursing documentation confirmed her blood sugar was rechecked due to the late meal. Other residents also reported not being informed about the delay and described significant hunger, with one rating their hunger as a nine out of ten. These observations and interviews confirm that the facility did not meet its obligation to serve meals at scheduled times according to residents' needs and preferences.
Food Safety and Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to meet food safety requirements in the kitchen, as evidenced by several specific deficiencies observed during a survey. Defrosted meat stored in the walk-in refrigerator was not labeled with a pull date or use by date, and several veggie sausage patties were stored past their use by date. Additionally, an unlabeled plastic bin containing meat was found, and the Director of Dining Services confirmed that proper labeling, including type of meat, pull date, and use by date, was required but not followed. The walk-in refrigerator's wall and floor were observed to have dirt, and food debris was found on the bottom of the dairy refrigerator, which contained items such as Jello, milk, and cottage cheese. The dairy refrigerator was reportedly cleaned twice a week and as needed, but was not maintained in a clean condition at the time of observation. Further, the snack refrigerator contained three bags of unlabeled grapes, and the Director of Dining Services confirmed that these should have been labeled with the date received to ensure safe storage times. In the dry storage room, a plastic rice scoop was found lying on top of a plastic bin of rice instead of being stored inside a clean bag as required, creating a risk of contamination. These failures were observed in a facility where the majority of residents received food prepared in the kitchen, and the facility's own policies and procedures required proper labeling, dating, and sanitation practices that were not followed.
Failure to Obtain and Document Complete Informed Consents for Care and Treatment
Penalty
Summary
The facility failed to ensure that accurate and complete informed consents were obtained for several residents, as required by its own policies and procedures. For multiple residents who lacked capacity to make their own medical decisions and had no legal surrogate, the required process involving the facility's Interdisciplinary Team (IDT) and inclusion of an unaffiliated resident representative, such as the Ombudsman, was not followed. In several cases, consent forms were either incomplete, missing required signatures, or improperly filled out, with sections for the resident's legal representative left blank or simply marked as 'IDT' without a signature or date. Interviews with the Administrator and DON confirmed that the Ombudsman had not participated in the Bioethics Committee/IDT meetings for over a year, contrary to facility policy, and that the Administrator should have signed as the responsible party on behalf of the IDT. For residents who were unable to make medical decisions, such as those prescribed psychotropic and antidepressant medications, the documentation of informed consent was inconsistent and incomplete. Forms for these residents often lacked the name and signature of the person who obtained consent, the date, and the required witness information. In some cases, the forms indicated that consent was obtained from the resident, despite documentation showing the resident lacked decision-making capacity. Additionally, for one resident, the consent for advanced wound care services was obtained from the resident, even though the medical record indicated the resident was unable to provide consent. Other deficiencies included missing or incomplete information on consent forms for residents who could make their needs known but not medical decisions. For example, forms were missing the date and signature of the person who placed a consent call, the date and signature of the eligible provider or clinician, the date and name/signature of a witness, and the date and signature of the resident or their power of attorney. In some cases, instructions for distributing copies of the consent forms were not followed, and the required information was not completed. Interviews with nursing staff and the DON confirmed these findings and acknowledged that the informed consents should have been properly signed and dated according to policy.
Failure to Update Care Plan for Aspiration Precautions
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident to reflect a physician's order for one-to-one feeding assistance as an aspiration precaution. Medical record review showed that the resident had a physician's order dated 3/27/25 for one-to-one feeding assistance, but this intervention was not included in the resident's active care plan addressing nutrition. During an observation, the resident was seen eating independently in his room without staff present and was noted to cough intermittently while swallowing. The Director of Nursing confirmed that the care plan had not been updated to include the required intervention in accordance with the physician's order.
Failure to Follow Physician Orders and Proper Monitoring Procedures
Penalty
Summary
The facility failed to provide necessary care and services to several residents as ordered by their physicians and as required by their care plans. For two residents with orders to monitor for orthostatic hypotension, the monitoring was not conducted correctly. Specifically, blood pressure (BP) measurements were not taken in all required positions (lying, sitting, standing) within the appropriate time intervals, and the physician's orders did not specify parameters for when to notify the physician of significant BP changes. Staff, including the DON and LVN, were unsure of the correct procedure and lacked facility policies or resources to guide them in monitoring orthostatic hypotension or determining when to notify the physician. Another resident with a physician's order for one-on-one feeding assistance due to aspiration precautions was not provided with the required assistance during meals. Observations and staff interviews confirmed that the resident was eating independently, contrary to the physician's order and the care plan, which specified one-on-one feeding assistance to prevent aspiration. The DON and LVN verified that the order was not being implemented by the facility staff. Additionally, two residents with orders and care plans specifying that blood pressure should not be taken on their left arms due to the presence of dialysis access devices had multiple BP readings documented as being taken from the restricted arm. Facility policy also prohibited BP measurements on the arm with a dialysis access device. Staff interviews and medical record reviews confirmed that these orders were not followed, and the DON acknowledged that BP should not have been taken on the left upper arm for these residents.
Failure to Provide One-to-One Feeding Assistance for Aspiration Precautions
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia and Alzheimer's disease, who had exhibited coughing or choking during meals and had a physician's order for one-to-one feeding assistance for aspiration precautions, was observed eating lunch independently in his room without staff supervision. The resident was seen consuming soup, juice, and a nutritional drink while intermittently coughing, and was outside the view of facility staff during the meal. The diet slip on the resident's tray did not include the physician's order for one-to-one feeding assistance. Interviews with the assigned CNA, LVN, Dietary Manager, and Director of Rehabilitation confirmed that the physician's order for one-to-one feeding assistance was active and that staff should have maintained visual supervision during meals. The CNA assigned to the resident was unaware of the order and allowed the resident to eat alone, contrary to the documented care plan and physician's instructions. The failure to communicate and implement the required supervision was verified through medical record review and staff interviews.
Deficiencies in Respiratory Care: Labeling, Documentation, and Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies in labeling, storage, and documentation of respiratory equipment and therapy. For one resident, the nebulizer tubing, mask, and canister were found unlabeled and not dated, with no indication of when they were last changed, despite a physician's order for regular nebulizer treatments. An LVN confirmed that these items should have been labeled and changed weekly or as needed. Another resident had a suction canister, tubing, and Yankauer suction tip that were not labeled or stored in a set-up bag, and the canister contained liquid of unknown age. The same resident was observed receiving oxygen at a rate higher than the physician's order, with no documentation of the administration or the reason for the increased flow. The LVN and RN involved confirmed the lack of labeling, improper storage, and missing documentation. A third resident was observed receiving oxygen therapy without a physician's order, and there was no documentation or reason for the administration. The DSD and LVN verified the absence of an order and documentation. Additionally, another resident's oxygen humidifier bottle was not dated as required by physician's order and facility policy. The DON acknowledged all these findings during interviews and record reviews.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication administration for three residents, as evidenced by direct observations, interviews, and medical record reviews. For one resident, the facility did not accurately document, sign out, or dispose of a narcotic medication (tramadol) according to its own policies and procedures. The medication administration record (MAR) and the controlled drug record did not match, and there was an unidentified, undated, and unlabeled tablet found attached to the narcotic bubble packet. Staff interviews confirmed that the required documentation and proper disposal procedures, including dual signatures for wasting narcotics, were not followed. Another resident with a physician's order for docusate sodium to be held in the presence of loose stool was administered the medication without the nurse assessing for current episodes of loose stool or diarrhea. Medical records showed the resident had a recent history of loose stool, and the nurse acknowledged not checking for this condition prior to administration. The DON confirmed that the medication should have been held as per the physician's order when loose stool was present. A third resident had a physician's order for losartan potassium to be held if the systolic blood pressure (SBP) was below 130 mmHg. Despite this, the MAR showed the medication was administered on multiple occasions when the resident's SBP was below the specified threshold. Both the nurse and the DON verified that the medication was given contrary to the physician's order, and the documentation supported this finding.
Deficient Medication Storage, Expired Supplies, and Unsanitary Medication Carts
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and disposal of drugs and biologicals within the facility. Inspections of several medication carts revealed that arformoterol, a medication used to treat chronic obstructive pulmonary disease, was not stored according to the manufacturer's instructions. Both unopened and opened unit dose vials of arformoterol were found in medication carts rather than in a refrigerator, as required. Staff interviews confirmed that the facility did not monitor the temperature of the medication carts to ensure compliance with the specified storage range, and the Director of Nursing acknowledged that the medication should have been refrigerated. Further observations found expired medical supplies and medications in multiple locations, including medication carts and the medication storage room. Items such as a small bore extension set, povidone-iodine swab sticks, a bottle of disinfectant, and COVID-19 antigen self-test kits were all found to be past their expiration dates and had not been properly discarded. Staff verified these findings and stated that expired items should have been removed from use and disposed of according to facility policy. Additionally, medication carts were found to be in unsanitary condition, with sticky residues and dried medication observed on bottles and cart surfaces. Staff confirmed that these carts should have been maintained in a clean and sanitary manner to ensure infection control. The facility's policies and procedures require proper storage, sanitation, and disposal of medications and supplies, but these were not followed as observed during the survey.
Failure to Provide Requested Meal Substitution
Penalty
Summary
The facility failed to ensure that posted meal menus and resident meal requests were followed for a specific resident. Review of facility documentation showed that the resident had submitted a special request for a tuna melt as a replacement for the posted meal entrée on a specific date. Despite this documented request, the resident was served the standard menu items, which included pork, beans, bread, cake with strawberries, and cranberry juice, but not the requested tuna melt. The resident, who was determined to have decision-making capacity, confirmed during an interview that she did not receive the meal she wanted and indicated that this was not a frequent occurrence. Interviews with facility staff, including an LVN and the Dietary Supervisor, confirmed that the resident's special meal request was missed and not provided as planned. The facility's policy required that food preferences and special requests be documented and followed, but this was not adhered to in this instance. The DON also verified the findings during a subsequent interview.
Failure to Honor Resident Food Preferences During Mealtime
Penalty
Summary
The facility failed to honor a resident's food preference as required by its policies and the resident's care plan. Specifically, a review of the resident's care plan indicated that their food preferences should be honored within diet parameters, and substitutes should be offered if meal intake was below 50%. The resident's diet slip specified a soft and bite-size Vietnamese menu with chopped meat, vegetables, noodles, and bread. However, during an observation, the resident was served ice cream and was not provided with the Vietnamese menu as requested. The resident in question had a fluctuating capacity to understand and make decisions, as documented in their medical record. During the observed mealtime, the resident verbally requested Vietnamese food, but the staff member feeding the resident confirmed that the Vietnamese menu was not served. This failure to provide the preferred food was contrary to the facility's policy on promoting and maintaining resident dignity during mealtime and had the potential to negatively impact the resident's meal intake and psychosocial well-being.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as required by its own policies and accepted professional standards. For multiple residents, there were inconsistencies between their capacity to make medical decisions as documented in their History & Physical (H&P) examinations and what was recorded on their admission face sheets. Specifically, some residents who were determined to lack capacity were incorrectly listed as self-responsible on their admission records, and updates to H&P examinations were not made after changes in cognitive assessments. Additionally, a resident's Advance Directive Acknowledgment form did not accurately reflect the existence of a completed POLST, despite one being present in the record. The facility also failed to ensure the accuracy of medication orders and documentation of clinical monitoring. One resident's physician order for metoprolol tartrate included an incorrect hold parameter for systolic blood pressure, which was verified by nursing staff as a documentation error. Furthermore, for two residents who had indwelling urinary catheters removed, the facility did not document urine output or use the bladder scanner to assess for urinary retention as required by facility policy. Instead, only check marks were recorded on the Treatment Administration Records (TARs), without accurate measurements of urine output or post-void residuals. These documentation failures were confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged the discrepancies and lack of accurate record-keeping. The facility's own policies require factual, accurate, and complete documentation, but these standards were not met in the cases reviewed, resulting in incomplete or inaccurate medical records for the affected residents.
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 6,422 citations issued within 25 miles in the last 12 months — including the 13 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) |
|---|---|---|---|---|
| Beach Creek Post-acute | 0.1 mi | ★★★★★ | 28 | 0 |
| Anaheim Crest Nursing Center | 0.6 mi | ★★★★★ | 30 | 0 |
| West Anaheim Medical Center D/p Snf | 0.6 mi | ★★★★★ | 16 | 0 |
| Buena Park Nursing Center | 1.1 mi | ★★★★★ | 47 | 0 |
| Anaheim Terrace Care Center | 1.2 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Anaheim Healthcare Center, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.