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 Point during CMS and state inspections, most recent first.
Incomplete informed consent for psychotropic medications was found for multiple residents. A resident with dementia and another resident with no decision-making capacity had psychotropic medication consents that were not properly signed or verified by the required LPNs, including telephone consent with only one nurse verification. Other residents’ consent forms for antidepressants, antianxiety medication, and antipsychotic medication were missing required details such as diagnosis, behavior manifestation, duration, and Caution and Warning Summary items like off-label use, FDA-approved use, and black box warning information.
A facility failed to monitor psychotropic meds in line with ordered target behaviors for three residents. One resident on Risperdal had a psychoactive summary that did not match the ordered behavior, another resident on quetiapine had repeated behavior episodes without documented NPI use, and a third resident on clonazepam had monitoring that was not updated after the order changed. The ADON, RN, and DON verified the findings.
A facility failed to provide proper GT care for two residents receiving tube feedings and medications. An RN did not check residual before flushing the tube and forced water and medications into the GT with a syringe plunger instead of using gravity flow. An LVN checked residual while the tube feeding pump was still running, did not hold the feeding before medication administration, omitted the initial water flush, and also pushed diluted medications into the GT with the syringe plunger when they did not flow by gravity.
Respiratory care was not provided as ordered for two residents receiving O2, with one resident observed on a higher flow rate than ordered and another on a lower flow rate than ordered. A third resident’s Yankauer suction tip was found stored under cloth underpads instead of in a set-up bag, and the record did not show an assessment or education for self-suctioning or proper storage of the suction equipment.
Kitchen sanitation and hand hygiene failures were observed when a Diet Aide rinsed hands in the ware washing sink and later used hand sanitizer instead of washing hands upon entering the kitchen, despite the DSS confirming handwashing was required. A cook was also observed using a fry pan with thick black residue, and the kitchen floor had broken tile with exposed cement in two areas; staff confirmed the floor condition was known. The facility matrix showed 127 residents received food prepared in the kitchen.
The facility failed to follow infection control practices in the clean linen area and during medication administration. Clean blankets and underpads were stored with personal items and other unrelated objects in the clean storage area, and an LVN and an RN did not perform hand hygiene or change gloves after contact with potentially contaminated surfaces before giving eye drops and insulin to two residents. The DON and IP were informed and acknowledged the findings.
Pests were observed in food service areas when a cockroach ran across the kitchen floor during meal prep and a gnat flew in the front dining room and landed on a resident's ice cream. Pest control reports showed prior treatment for cockroaches and noted door gaps and a damaged sweep at the rear door, while service reports did not show an inspection of the front dining room. The facility's matrix showed 127 residents received food prepared in the kitchen.
A resident with neurogenic bladder and an indwelling urinary catheter was observed in bed with the catheter drainage bag not placed inside the dignity bag, exposing a scanty amount of yellowish urine. A follow-up observation with the IP nurse confirmed the bag was still not inside the dignity bag, and the DON was made aware of the finding.
Call Lights Not Within Reach for Two Residents: Two residents who had capacity to make medical decisions were observed in bed with their call lights out of reach, one hanging behind the headboard and the other on the floor beside the bed. One resident said she needed the call bell for pain medication and could not find or reach it. The DON and CNA verified the findings, and the facility policy stated the call alert device should be placed within the resident’s reach.
The facility failed to send the LTC Ombudsman a copy of the Notice of Proposed Transfer and Discharge for two residents transferred to acute care hospitals. One resident was transferred for elevated WBC and another for desaturation and SOB; both records lacked evidence that the notice was completed and faxed. Staff interviews showed confusion about who was responsible, and the DON stated staff had stopped sending the form after being told it was not needed.
The facility failed to develop and/or follow comprehensive care plans for three residents. One resident on continuous O2 was observed with the HOB flat despite care plan interventions calling for upright positioning and HOB elevation; another resident had a low air loss mattress with bolsters used for safety, but the care plan did not address bolster use for that purpose; and a third resident independently self-suctioned with a Yankauer, but the care plan did not include a problem for self-use of suction equipment.
A resident’s care plan for depression and anxiety did not include ordered nonpharmacologic interventions tied to duloxetine and alprazolam, even though the physician required behavior monitoring and specific NPI options. Another resident’s care plan also failed to reflect that the resident disliked the facility food and received food brought in daily from home, which the RD confirmed should have been documented.
A resident who required total care was observed with thick white residue covering the tongue, despite a care plan calling for daily oral hygiene and monitoring of oral problems. Another resident who was dependent on staff for bathing stated she was not given showers on scheduled days and did not refuse them; review of CNA task records and shower inspection sheets showed missing documentation for several scheduled shower days, and staff confirmed the gaps.
Failure to Administer PRN Midodrine for Low BP: A resident with an order for midodrine 10 mg PO q8h PRN for hypotension when SBP was less than 110 mmHg had multiple shift BP readings below the ordered threshold, but the MAR did not show the medication was given. RN verified the resident was not administered midodrine numerous times when the SBP was low, and the DON confirmed the findings.
A resident with a fluid restriction for CHF had inconsistent and conflicting fluid intake documentation between CNA task records and nurse intake/output records, with CNA totals often exceeding the nurse-documented totals. The resident was observed with a pitcher of ice and thickened water at bedside, and staff confirmed the intake records were not aligned and that fluid overload monitoring did not occur when limits were exceeded. In a separate event, an LVN failed to administer an ordered daily Nephro oral liquid supplement during a med pass, even though it was listed on the MAR.
A facility failed to provide proper pain management for two residents. One resident received hydrocodone without a documented pain assessment before each dose, despite an order to monitor pain every shift and use a 0-10 scale. Another resident, who had moderate cognitive impairment, was given hydrocodone multiple times even though the MAR documented a pain level of 0, which did not match the physician’s severe-pain parameter. The ADON and DON acknowledged the findings.
A resident receiving HD had a 1-liter fluid restriction, but CNA meal-fluid documentation and the LPN intake/output record were inconsistent and incomplete, with several days showing intake above the ordered limit or missing totals. The resident’s HD access was also documented as positive for redness, swelling, drainage, and pain on multiple shifts, yet there was no documentation of further monitoring or notification to the MD, nephrologist, or dialysis facility. The RN and DON verified the findings.
Two nurses were found incompetent in GT medication administration during direct observation. An RN failed to check GT residual before flushing, pushed water and medications into the tube with the syringe plunger instead of using gravity, and did not verify patency when flow stopped. An LPN checked residual while the TF pump was still running, administered a medication without flushing first, and also pushed medications into the GT with the syringe plunger when they would not flow by gravity. Both nurses confirmed the observations, and the DON stated competency validation included medication administration via all routes.
Failure to Post Required Nurse Staffing Information: The facility did not have CDPH Form 612 posted in a prominent, accessible location for residents and visitors. An observation found only the daily projected nurse hours posted, and the DSD verified that the actual hours worked by licensed and unlicensed nurses were not posted.
A resident approved for self-administration had fluticasone propionate nasal spray left on the bedside table instead of being stored in a secured location. Surveyors observed the medication at the bedside, and an LVN and RN both stated the resident could keep it there, despite the facility P&P describing secured storage for approved self-administration medications. The resident was cognitively intact and had no upper-extremity impairment, and the DON was informed of the finding.
Kitchen Employee Hand Hygiene and Sanitizer Testing Deficiencies: A dietary aide did not demonstrate the required competency for hand hygiene and sanitizer testing. He rinsed his hands in the ware washing sink after handling soiled dishes, later used hand sanitizer instead of washing his hands when entering the kitchen, and incorrectly tested the quat sanitizing solution, with the DSS confirming that handwashing is required and sanitizer cannot replace it.
A resident with a physician-prescribed Regular Vegetarian diet was served a veggie patty meal that provided less protein than the regular meal option. Facility staff said the vegetarian menu was not followed, the RD was not involved in ensuring nutritional needs were met, and the resident's nutrition assessment did not document the vegetarian diet or recommend protein or nutritional supplements.
Failure to educate visitors and staff on safe handling of food brought from outside. A resident was eating ethnic food brought daily by a family member from his church and stored in reused plastic containers. The resident’s husband said he had not received any safe food handling information, and the DON confirmed no written guidance was provided to residents or visitors. The DSD also confirmed she had not in-serviced staff on safe food handling.
A resident's personal belongings, including valuable items, were not labeled with her name or included in her inventory list. Despite the resident informing staff and providing updates, the inventory was not updated and the facility's policy for labeling and documenting property was not followed. Staff confirmed the inventory was outdated and the belongings were not properly recorded.
The facility did not follow its abuse prevention policy when a resident alleged emotional distress caused by two LVNs. Despite the policy requiring immediate suspension of accused staff pending investigation, the nurses remained on duty during the inquiry. The administrator acknowledged not following the policy, and both nurses confirmed they were not suspended while the investigation was conducted.
Surveyors found that several residents were self-administering medications such as eye drops, pain relief creams, and sprays without required assessments, physician orders, or care plan documentation. Nursing staff confirmed that the facility's policy for evaluating and authorizing self-administration was not followed, and medical records lacked necessary approvals and documentation.
A resident who is always incontinent and has a high BMI did not receive a properly fitted diaper after the facility's vendor stopped supplying the preferred brand and size. The resident reported discomfort and repeated bed wetting, and a CNA confirmed the provided diapers were too small. The issue persisted for at least two weeks despite the resident's requests.
A resident with dementia and a history of falls had a care plan requiring floor mats on both sides of the bed. Observations showed that only one mat was in place, and an LVN confirmed the care plan was not fully implemented, resulting in a deficiency.
The facility did not ensure continuous monitoring and documentation for a resident receiving IV antibiotics for a urinary tract infection, as required by policy, and failed to clearly identify and communicate the code status for another resident with severe cognitive impairment on hospice. Nursing staff were unable to immediately determine the code status due to incomplete documentation, and monitoring for adverse reactions to antibiotics was not performed or recorded as expected.
Two residents were not adequately protected from accident hazards: one with severe cognitive impairment was able to leave the facility undetected after episodes of wandering and expressing a desire to go home, without timely updates to the care plan or staff communication; another resident at high risk for falls did not have bilateral floor mats in place as ordered by the physician, with only one mat observed during multiple checks.
A resident with ESRD receiving regular dialysis did not have their AV shunt site consistently or appropriately assessed for bruit and thrill as required by physician orders and facility policy. Documentation showed multiple instances where the absence of bruit and thrill was recorded, but there was no evidence that a physician was notified. Staff interviews confirmed a lack of understanding and follow-through regarding documentation and notification protocols.
A resident with severe cognitive impairment and dependent for bed mobility was provided with bilateral upper half side rails, despite an assessment indicating side rails were not needed. The care plan addressed grab bars rather than side rails, and staff confirmed the discrepancy between the assessment and the actual use of side rails, resulting in exposure to accident hazards.
A resident received hydrocodone-acetaminophen for severe pain, but the administration of this controlled medication was not documented on the Medication Administration Records as required by facility policy. Both an LVN and the DON confirmed the absence of documentation for two instances when the medication was dispensed.
Expired culture swabs and wound dressings were found in a treatment cart, and a resident was observed with an unopened container of over-the-counter eye drops at their bedside without a physician's order. Both issues were acknowledged by nursing staff and the DON, and the resident involved had moderately impaired cognition.
A resident on a NAS diet with specific dietary preferences did not receive the required protein components in her chef salad, receiving only lettuce, shredded carrots, and purple cabbage instead of the full recipe. The resident, who was trying to lose weight for knee surgery, reported not receiving enough protein, and facility staff confirmed the salad was not prepared according to the established recipe.
A resident with a history of stroke and a contracted, weak hand was not provided with the required built-up utensils and lip plate during meals, as ordered by the physician and documented in the care plan. Observations showed the resident using regular utensils, and staff confirmed the need for adaptive equipment to assist with eating.
Staff failed to wear required hair restraints in the kitchen and did not properly cover a canister of brown rice in dry storage, as confirmed by the Dietary Services Supervisor and Cook. These lapses occurred while preparing food for a large number of residents, in violation of facility infection control and food storage policies.
Two residents receiving hospice care did not have proper documentation or assurance of scheduled hospice aide visits, with missing records for several weeks and incomplete hospice consent forms. Facility and hospice staff confirmed the lack of documentation and unclear visit schedules, resulting in incomplete records and uncertainty about whether hospice services were provided as ordered.
A resident with severe cognitive impairment and dependent for bed mobility was observed using bilateral upper side rails without documented evidence of a required bed entrapment assessment. Facility policy mandated such assessments upon admission or changes in bed equipment, but the maintenance department was not notified about the resident's bed, and inspection logs showed no record of assessment for this bed.
The facility did not implement required testing and monitoring of disinfectant chemical levels in its water supply as outlined in its water management and Legionella control policies. Additionally, the laundry room and equipment were observed to be unclean, with visible stains, residue, and wall damage, as confirmed by the Housekeeping Supervisor.
The facility failed to implement its antibiotic stewardship program, resulting in inconsistent and inaccurate infection control documentation, lack of clear use of McGeer's criteria for infection assessment, and discrepancies in the evaluation and documentation of a resident who was prescribed antibiotics for diarrhea. These failures were acknowledged by the IP and DON.
A resident who was discharged home with hospice services was incorrectly coded in the MDS as being discharged to a short-term general hospital. The MDS Coordinator confirmed the error, which was made by the MDS Assistant, and the DON acknowledged the findings during review.
The facility did not ensure that POLST forms for two residents included documentation regarding advance directives, and medical records for two other residents were found incorrectly filed in another resident's chart. These documentation errors were confirmed by nursing staff during record reviews.
Two of six facility dumpsters were found with lids open and garbage inside, with the refuse preventing the lids from closing fully. This was observed and verified by the Administrator, and the condition did not comply with requirements for tight-fitting lids to prevent pest entry.
A resident's care plan was not updated to include treatment for left foot arterial wounds, despite physician orders. The omission was confirmed by the DON, highlighting a failure to provide individualized care.
A facility failed to ensure a resident receiving enteral feeding via a PEG tube was positioned with the head of the bed elevated 30 to 45 degrees, as required by policy. The resident was observed lying flat while receiving Jevity 1.5 at 50 ml per hour, posing a risk of aspiration. This was confirmed by an LVN and acknowledged by the DON.
A facility failed to ensure proper PPE use during high-contact care for a resident with a PEG tube, Foley catheter, and wounds. A CNA was observed handling the resident's Foley catheter without gloves and a gown, contrary to the facility's Enhanced Barrier Precautions policy. This lapse was confirmed by interviews with the CNA, an RN, and the DON.
A facility failed to store a resident's medication properly, as a bubble pack of potassium chloride was found on the nursing station counter instead of in the medication cart. An LVN confirmed the medication belonged to a resident and acknowledged it should have been stored securely. The ADON was informed and took possession of the medication.
A facility failed to inventory a resident's personal property upon admission and discharge, leading to missing items. The resident reported missing belongings after returning from a hospital transfer, but the social worker did not document the inventory. The DON confirmed the lack of documentation, highlighting a deficiency in safeguarding resident property.
A resident reported feeling humiliated after a CNA threw towels at her and instructed her to dry herself without assistance. The Activities Assistant documented some allegations but failed to report a specific incident to the Administrator, who was unaware of the allegations. The facility did not implement its policies and procedures related to abuse reporting, risking inadequate investigation and prevention of further abuse.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure valid informed consent for psychotropic medications and treatments for multiple residents. Review of the facility’s policies showed that written informed consent was required for psychoactive drugs, with renewal every six months, and that the licensed nurse was to verify informed consent before the first dose or first increased dose. The facility also had an instruction sheet for the Psychotherapeutic Drug Informed Consent Form requiring the Caution and Warning Summary section to identify whether the medication was off-label use, FDA-approved use, and whether it carried a black box warning label. For Resident 2, the record showed diagnoses of dementia and inability to understand and make treatment decisions. The resident had orders for quetiapine for psychosis manifested by sudden angry outburst and trazodone for depression manifested by inability to sleep. The quetiapine informed consent was documented as given by the resident, but the resident did not sign the form and only one licensed nurse verified it. The trazodone consent was given by the resident’s representative via telephone, but only one licensed nurse verified the consent. For Resident 6, who had no decision-making capacity, the physician ordered quetiapine for schizoaffective disorder manifested by striking out. The informed consent form for quetiapine did not include the diagnosis, the behavior manifestation related to the medication, or the duration for use as ordered. For Resident 11, who had no capacity to understand and make decisions, the alprazolam consent form showed the resident gave consent but did not sign, and only one licensed nurse verified it. For Resident 13, the trazodone consent form did not show the resident’s signature, and the clonazepam consent form did not complete the Caution and Warning Summary to show whether the medication was off-label use and FDA-approved use. For Resident 3 and Resident 61, the consent forms for duloxetine, escitalopram, and trazodone did not complete the Caution and Warning Summary to show off-label use, FDA-approved use, and, where applicable, black box warning information.
Psychotropic Medication Monitoring Not Aligned With Ordered Target Behaviors
Penalty
Summary
The facility failed to ensure that psychotropic medications were monitored according to the documented target behaviors for three residents. Review of the facility policy showed that licensed nurses were to identify contributing factors and non-medication interventions, and that psychoactive medications were to be reassessed for effectiveness. The deficiency involved Resident 5, Resident 6, and Resident 13, all of whom had no decision-making capacity documented in their records. For Resident 5, the physician ordered Risperdal for psychosis manifested by sudden angry outburst, but the medical record did not show that this target behavior was monitored as ordered. The resident’s psychoactive summary sheet for May 2026 showed one behavior episode on the morning shift, but it did not match the behavior being tracked under the physician’s order. The ADON verified that when the order was updated, the monitoring for the target behavior should have been updated as well, and that the monthly psychoactive summary sheet should match the target behavior being monitored. For Resident 6, quetiapine was ordered for schizoaffective disorder manifested by striking out, with orders to monitor target behaviors and document nonpharmacological interventions. The MAR showed multiple behavior episodes across May and June 2026, but the record did not show documented evidence that nonpharmacological interventions were implemented when those behaviors occurred. For Resident 13, clonazepam was ordered for anxiety manifested by verbalization of feeling anxious, and later updated to PRN use for anxiety manifested by increased agitation, but the record did not show that monitoring was updated to reflect the revised target behavior. RN 2 and the DON verified the findings for Resident 13.
GT Medication Administration and Tube Care Errors
Penalty
Summary
The facility failed to ensure appropriate gastrostomy tube (GT) care and services were provided for two residents receiving enteral nutrition and medications via GT. Facility policies required verification of tube placement and patency before intermittent feeding, hydration, and medication administration, including aspiration of gastric contents, returning aspirate to the stomach, flushing with water, and administering medications by syringe via gravity flow. For one resident, RN 1 did not check GT residual before flushing the tube with 30 ml of water. When the water did not flow during a second flush attempt, RN 1 used the syringe plunger to force the water into the GT instead of allowing gravity flow. RN 1 also used the syringe plunger to push multivitamins and Senna into the GT when the medications were not flowing down the tube. During interview, RN 1 confirmed these actions and stated the residual should have been checked first and the medications should have been allowed to flow by gravity. For the second resident, LVN 2 checked the GT residual and returned 10 ml of aspirate while the tube feeding pump was still running. LVN 2 then began medication administration before placing the tube feeding on hold, and administered valproic acid liquid without first flushing the GT with water. LVN 2 also administered diluted Namenda and folic acid, added water, and when the medications did not flow down the GT, used the syringe plunger to push them into the tube. LVN 2 confirmed the findings and stated the tube feeding should have been held before residual checks and medication administration, that the GT should have been flushed with 15 ml of water before medications, and that medications should have flowed by gravity or the tube patency should have been checked if they did not.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide respiratory care as ordered for two residents receiving oxygen. Resident 8 was observed receiving oxygen at 3.5 liters per minute via nasal cannula, although the physician order was for 2 liters per minute via nasal cannula to keep oxygen saturation at 94% or above every shift. During follow-up observation, an LVN verified the oxygen was still set at 3.5 liters per minute and stated only the RN changes the oxygen setting. Resident 148 was observed with oxygen via nasal cannula set at 1.5 liters per minute, although the physician order was for 2 liters per minute via nasal cannula to keep oxygen saturation at or above 92% every shift for acute hypoxic respiratory failure. A DSD verified the oxygen was set at 1.5 liters per minute and stated the physician order was for 2 liters per minute. The facility also failed to properly manage suction equipment for Resident 126. The resident had a physician order allowing suction as needed for increased secretions and congestion, and was observed asleep with a Yankauer suction tip placed underneath cloth underpads. An RN verified the suction tip was under the underpads and stated the resident suctions herself and wanted it nearby. The RN then labeled a new set-up bag and placed the Yankauer suction into it. The medical record did not show that Resident 126 had been assessed or educated on how to independently suction herself or how to store the Yankauer suction when not in use.
Kitchen sanitation and hand hygiene failures
Penalty
Summary
Food safety and sanitation guidelines were not followed in the kitchen when proper hand hygiene was not maintained, food preparation equipment was not clean, and the kitchen floor was not intact. The facility’s dietary infection control policy stated that staff must perform proper hand hygiene upon entering the kitchen and after handling soiled equipment or utensils, and that kitchen sinks are not to be used for hand washing. During observation of the dishwashing process, a Diet Aide loaded soiled dishes while wearing gloves, removed the gloves, rinsed his hands in the manual ware washing sink, and then picked up clean dishes from the clean side of the dishwashing machine. Later, the same Diet Aide entered the kitchen and used hand sanitizer instead of washing his hands in the hand-washing sink before returning to work. The Dietary Services Supervisor confirmed that kitchen employees must wash their hands when entering the kitchen and that hand sanitizer is not to be used in place of handwashing. During meal preparation, a cook was observed preparing onions in a fry pan that had thick black residue on the inside. In addition, the kitchen floor had two areas, one in the dish room and one near the grill, where the tile was not intact and cement was exposed. The Maintenance Supervisor stated he was aware of the condition of the kitchen floors, and the Maintenance Director confirmed the Administrator had not received any quotes to repair the floors. The facility matrix showed 127 residents received food prepared in the kitchen.
Infection Control Failures During Linen Storage and Medication Administration
Penalty
Summary
The facility failed to implement infection control practices intended to maintain a safe and sanitary environment and prevent the spread of disease and infection. During observation of the laundry area, clean storage for blankets contained a black purse on top of a blanket and a book on top of another folded blanket. The clean storage area for blue underpads also contained a worn and damaged bag used to store the underpads, along with a white binder, sewing kit, small container of grape jelly, black plastic folder, roll of tissue, and a small cup stored within the same area. The Housekeeping Supervisor verified these findings, and the DON was later informed and acknowledged them. The facility also failed to ensure proper hand hygiene and glove changes during medication administration. While administering eye drops to Resident 25, an LVN touched the privacy curtain with gloved hands and then administered the medication without performing hand hygiene or changing gloves after administering oral medications. During another observation, an RN administered insulin to Resident 88 immediately after giving the resident medications via GT without performing hand hygiene or changing gloves. Both nurses acknowledged the actions during interview, and the IP and DON were informed and acknowledged the findings.
Pests Observed in Kitchen and Dining Room
Penalty
Summary
The facility failed to ensure the kitchen and front dining room were free of pests. During a lunch meal preparation observation in the kitchen, a cockroach was seen running across the kitchen floor next to the oven, and a staff member verified seeing it. The facility's pest control reports from prior visits documented that the kitchen interior had been treated for cockroaches and noted structural concerns, including a rear door hole or gap that needed sealing, gaps on both sides of the frame, and a door sweep needing replacement to sit flush to the floor. During a dining observation in the front dining room, a gnat was observed flying around the room and landing on a resident's cup of ice cream, and an LVN verified the finding and discarded the ice cream. The Maintenance Director stated there had been no reports of gnats in resident rooms or the dining room, and review of pest control service reports showed visits on multiple dates but did not show an inspection of the front dining room. The facility's matrix showed 127 residents received food prepared in the kitchen.
Failure to Keep Urinary Catheter Drainage Bag in Dignity Bag
Penalty
Summary
The facility failed to promote dignity and respect for Resident 15 by not ensuring the resident’s indwelling urinary catheter drainage bag was placed inside the dignity bag. During an initial tour on 6/16/26, Resident 15 was observed lying in bed with the indwelling urinary catheter on the left side of the bed, and the drainage bag was not inside the dignity bag, exposing a scanty amount of yellowish urine. On 6/17/26, a follow-up observation and interview with the IP nurse confirmed the drainage bag was still not inside the dignity bag. Resident 15 was admitted and later readmitted to the facility with a diagnosis of neurogenic bladder, and the medical record showed a physician’s order for an indwelling urinary catheter size FR#16 with balloon via gravity drainage for neurogenic bladder.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to provide reasonable accommodation for two residents by not keeping their call lights within reach. The facility's policy titled Communication-Call System, revised 8/24/24, stated the call alert device would be placed within the resident's reach. Resident 52 was admitted and later readmitted to the facility, and the H&P dated 8/18/25 showed the resident had the capacity to understand and make medical decisions. On 6/16/26 at 1028 hours, Resident 52 was observed lying in bed with the call light hanging behind the headboard, out of reach. The resident attempted to reach it but could not and refused interview. At 1112 hours, the DON observed the same condition and stated the call light should be within reach of every resident so assistance could be requested. Resident 90 was also admitted and later readmitted to the facility, and the H&P dated 7/8/25 showed the resident had the capacity to understand and make medical decisions. On 6/16/26 at 1056 hours, Resident 90 was observed lying in bed with the call light on the floor on the left side of the bed, far from reach. The resident stated having no idea where the call light was, said she needed it to call staff for pain medication, and attempted but was unable to find or reach it. At 1058 hours, CNA 2 was summoned, verified the call light was on the floor away from the resident, and placed it back on the bed. On 6/19/26 at 1400 hours, the DON acknowledged the findings and stated the call light should be within the resident's reach to ensure safety and allow communication with staff when assistance was needed.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide a copy of the Notice of Proposed Transfer and Discharge to the office of the State Long-Term Care Ombudsman for a resident transferred to an acute care hospital on 4/29/26. The resident had a physician order to transfer to Acute Care Hospital 2 for further evaluation due to elevated WBC and a 7-day bed hold, but the medical record did not show documented evidence of the notice or that the Ombudsman was notified. During interview, the ADON verified the notice was not found in the record and stated the facility had stopped filling out the form because the Ombudsman had told staff it did not need to be faxed when a resident transferred to the hospital, although the ADON acknowledged the facility should have sent it so the Ombudsman would have a record of the transfer. The facility also failed to send the Ombudsman a copy of the transfer/discharge notice for a closed-record resident discharged to an acute care hospital on 4/5/26. The resident’s MDS showed moderately impaired cognition, and the physician ordered transfer via 911 due to desaturation and SOB with a 7-day bed hold if admitted. The closed record did not contain evidence that the Ombudsman was notified. During interviews, the SSD stated social services did not complete notices for residents sent to the hospital, while RN 2 stated medical records staff were responsible for faxing the notice to the Ombudsman for hospital transfers. The DON stated licensed nurses or medical records staff used to fax the form, but staff stopped doing so after being told by the Ombudsman that the notification was not needed.
Incomplete Care Plans for Oxygen Positioning, Bed Bolster Use, and Self-Suctioning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that reflected the individual care needs of three residents. For one resident, the care plan addressed oxygen therapy and included interventions to position the resident to support ventilation and lung expansion, including elevating the head of the bed to 45 degrees if tolerated, but the resident was observed receiving oxygen while the head of the bed was flat. A LVN later verified the head of the bed was in a flat position. For another resident, the physician ordered a low air loss mattress with bolster for skin management, and the resident was observed in bed with upper and lower bolsters on each side. The care plan addressed skin integrity concerns and included the low air loss mattress with bolster as ordered, but staff stated the bolster was being used for safety to prevent the resident from sliding out of bed and verified there was no care plan problem addressing the bolster for that purpose. For the third resident, a physician order allowed suctioning as needed for increased secretions and congestion. The resident was observed with a Yankauer suction tip kept under cloth underpads and independently using the suction equipment, including dipping the suction tip into water while the suction machine was turned on. Review of the care plan did not show a problem addressing the resident's self-use of suction equipment, and nursing staff verified that the resident independently suctioned herself.
Care plans were not updated to match residents’ current needs and ordered interventions
Penalty
Summary
The facility failed to ensure the comprehensive person-centered care plan was revised to reflect current care needs and interventions for two residents. For Resident 11, who was readmitted to the facility and had no capacity to understand and make decisions, physician orders dated 5/13/26 required monitoring target behaviors for duloxetine used for depression and alprazolam used for anxiety, with nonpharmacological interventions documented by specific options such as music/TV, redirecting, reassurance, quiet environment, or other listed interventions. The resident’s care plan had a focus problem for depression and duloxetine revised on 4/7/26 and a focus problem for anxiety and alprazolam revised on 5/14/26, but the interventions did not include the nonpharmacologic interventions ordered by the physician. For Resident 133, the family member stated the resident was a vegetarian, did not like the facility food, and received food brought daily from home, including food obtained from the family member’s church. During record review and interview, RD 2 confirmed the care plan did not include that Resident 133 disliked the facility food or that food was being brought in daily from outside the facility. RD 2 stated this information should have been included in the resident’s care plan.
Failure to Provide Oral Care and Scheduled Showers
Penalty
Summary
The facility failed to provide necessary ADL care for two residents. One resident, who was non-verbal, NPO, and required total care with oral hygiene, was observed with the mouth open and the tongue sticking out, covered with thick white residue. The resident’s record showed substantial/maximal assistance was needed for oral hygiene, and the care plan directed staff to monitor and report oral problems, including a tongue that was black, coated, inflamed, white, or smooth, and to provide good oral hygiene daily. During interviews, a CNA stated oral care had been provided but the tongue remained covered with thick white residue, and the LVN later verified the condition and stated she had not been aware of it. The facility also failed to ensure another resident received showers on scheduled shower days. That resident stated she was not given showers on her scheduled days, did not refuse showers, and felt frustrated, angry, and neglected. Her record showed she had moderate cognitive impairment and was dependent on staff for showering or bathing. The CNA task documentation showed shower/bed bath entries as not applicable on some scheduled days, a bed/towel bath on one date, and showers on other dates, but there was no documentation showing a shower or bed bath, or a refusal, on several scheduled shower days. Facility staff confirmed the resident was scheduled for showers on Wednesday and Saturday, and that CNAs were expected to complete shower inspection sheets and document refusals or bed baths in the task record. Review of the shower inspection sheets and task documentation showed missing documentation for multiple scheduled shower days. The DON verified there were no documented showers or bed baths provided on those dates.
Failure to Administer PRN Midodrine for Low Blood Pressure
Penalty
Summary
The facility failed to provide Resident 61 the prescribed midodrine 10 mg by mouth every eight hours as needed for hypotension when the resident’s systolic blood pressure was less than 110 mmHg. The physician’s order also required blood pressure monitoring every shift for midodrine use. Review of the June 2026 MAR showed that Resident 61’s blood pressure was checked every shift, and multiple readings were documented with systolic blood pressures below 110 mmHg, including readings of 106/52, 101/50, 103/61, 102/64, 108/63, 99/52, 103/57, 106/60, 104/45, 102/62, 91/37, 106/64, 98/50, 102/53, 104/63, 99/51, 96/46, and 92/47 mmHg. Despite these documented low systolic blood pressure readings, the MAR did not show that Resident 61 was administered midodrine when the blood pressure was below the ordered threshold. During interview and concurrent record review, RN 2 stated that charge nurses checked vital signs every shift and would give midodrine if the systolic blood pressure was less than 110 mmHg, and RN 2 verified that the medication was not given numerous times when the resident met that parameter. The DON also verified the findings.
Inaccurate fluid monitoring and missed ordered supplement
Penalty
Summary
The facility failed to monitor fluid intake accurately for Resident 126, who had a physician’s order for a 1200 ml per day fluid restriction for CHF exacerbation. The resident’s chart contained two different sources of fluid intake documentation for June 2026: the CNAs recorded intake in the Task documentation, and the licensed nurses recorded intake in the Intake and Output Monitoring record. The CNA-documented totals and the licensed nurse-documented totals did not match, and the CNA totals often exceeded the amounts documented by the licensed nurses. The record also showed that the daily fluid intake documentation was inconsistent and incomplete. During observation on 6/17/26, Resident 126 was seen in bed with a pitcher of ice and a cup of thickened water at bedside. CNA 3 stated the resident was on fluid restriction and was only given a pitcher of ice and a cup of thickened water at bedside, and that the resident’s intake from the cup and meal trays was documented under Task documentation. CNA 3 also stated ice intake was not counted. RN 2 verified that the resident’s fluid intake from dietary and meal trays was documented by CNAs on the Task documentation, while the licensed nurses’ Intake and Output Monitoring record was supposed to include total intake from nursing and dietary sources. RN 2 further verified that the Task documentation was inconsistent with and exceeded the Intake and Output Monitoring record, and that the resident was not monitored for fluid overload when the fluid limit was exceeded. The facility also failed to provide Resident 25’s ordered Nephro oral liquid supplement. Resident 25 had a physician’s order for Nephro oral liquid 237 ml by mouth one time daily, scheduled for 0900 hours. During a medication administration observation, LVN 1 administered the resident’s other ordered medications and supplements, including Pro-stat, but did not administer the Nephro supplement. Later review of the MAR and interview with LVN 1 confirmed that the Nephro oral liquid was scheduled but was not given during the observed medication pass. The DON was informed and acknowledged the findings.
Pain Medication Given Without Required Pain Assessment or Accurate Pain-Level Documentation
Penalty
Summary
The facility failed to provide necessary pain management for Resident 13 by not assessing pain before administering hydrocodone-acetaminophen ordered as needed for severe pain. The resident’s physician order required pain monitoring every shift and documentation using a 0-10 pain scale, but the MAR showed multiple hydrocodone administrations throughout June 2026 without a documented pain assessment before the medication was given. Pain monitoring entries were only found on three evening shifts, and the record did not show pain was assessed prior to the hydrocodone doses. RN 2 and the DON both verified that the resident was not assessed for pain before the medication was administered. The facility also failed to accurately document pain levels for Resident 90 according to the physician’s order. Resident 90 had moderate cognitive impairment and was ordered hydrocodone-acetaminophen for severe pain rated 7-10, first every 6 hours and later three times daily. The MAR showed the medication was administered repeatedly with the pain level documented as 0 at the time of administration on numerous occasions. During interview and record review, the ADON verified the findings and stated nurses should follow the physician’s order and administer the pain medication per the pain level parameter, and that Resident 90 should not have received the medication when the pain level was 0. The DON was later informed and acknowledged the findings.
Inconsistent fluid monitoring and lack of notification for positive dialysis access findings
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident receiving hemodialysis. The resident had a physician order for a 1-liter-per-day fluid restriction, with the limit divided between dietary and nursing intake documentation. Facility policy required diet and fluid restrictions to be followed as ordered and access sites to be assessed, observed, and documented daily for signs of infection such as drainage, redness, and tenderness. The resident’s record showed hemodialysis access monitoring orders for bruit and thrill every shift and for redness, swelling, drainage, and pain every shift, with physician notification if findings were positive. Review of the resident’s fluid intake documentation showed inconsistency between CNA task documentation and the licensed nurses’ Intake and Output Monitoring record. The CNA documentation for June 2026 included multiple days with no recorded intake for meals and several days where the documented dietary fluid intake exceeded the ordered daily limit, including totals of 1,300 ml, 1,020 ml, 730 ml, 640 ml, 1,480 ml, 960 ml, 1,020 ml, and 1,190 ml. The licensed nurses’ record also showed totals that did not consistently match the CNA documentation and included incomplete entries, such as missing 24-hour totals on some days and one day where the 24-hour total was recorded as 360 ml despite a total fluid intake of 660 ml. The resident’s MAR showed the hemodialysis access was assessed positive for redness, swelling, drainage, and pain on three occasions, but there was no documentation that the resident was further monitored or that the physician was notified. The record also did not show notification to the dialysis facility or nephrologist regarding the fluid intake or the access-site findings. During interview, the RN verified the intake documentation was inconsistent and incomplete and confirmed the resident was not monitored for fluid overload and that notifications were not made. The DON also verified the findings and stated that the nurses completed the 24-hour calculation and weekly intake and output evaluation, and that positive access findings would generate a change of condition.
Incompetent GT Medication Administration by Two Nurses
Penalty
Summary
The facility failed to ensure two licensed nurses had the competencies needed to safely administer medications via gastrostomy tube (GT). The deficiency involved RN 1 and LVN 2, both of whom were reviewed for feeding tube medication administration competency. The report states that the facility’s job descriptions required nurses to provide care within their scope of practice and to administer medications as ordered, and that the DON said licensed nurses were evaluated on medication administration skills upon hire, at three months, annually, and as needed. During an observation of medication administration for one resident with a GT, RN 1 did not check GT residual before flushing the tube with 30 mL of water. When the water did not flow down the GT on a second attempt, RN 1 used the syringe plunger to push the water into the tube instead of allowing gravity flow. RN 1 then used the same technique when administering multivitamins and Senna after the medications were not flowing down the GT. RN 1 later verified these findings and stated she should have checked the residual first, should have allowed medications to flow by gravity, and should have checked GT patency when the medications were not flowing. During a separate observation for another resident with a GT, LVN 2 checked the GT residual and flushed back 10 mL while the tube feeding pump was still running. LVN 2 was about to administer the first diluted medication while the pump was still on, then held the feeding after being questioned. LVN 2 administered valproic acid liquid without flushing the GT first with water, and later administered diluted Namenda and folic acid while the medications did not flow down the GT, using the syringe plunger to push them into the tube rather than allowing gravity flow. LVN 2 confirmed the findings and stated the GT should have been flushed with 15 mL of water before medications and that medications should have flowed by gravity or the tube patency should have been checked if they did not.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place and readily accessible to residents and visitors. During observation, there was no CDPH Form 612, Nurse Staffing Information, showing the actual hours worked by licensed and unlicensed nurses posted in any prominent area of the facility that residents and visitors could access. During an interview and concurrent observation, the DSD stated that the facility only had the daily projected hours posted for licensed and unlicensed nurses and verified that the actual hours worked were not posted. The Administrator and DON were later informed of these findings and acknowledged them.
Improper Storage of Self-Administered Medication
Penalty
Summary
The facility failed to provide the necessary pharmacy services to ensure proper storage of medication for one of 29 sampled residents, Resident 13, who was reviewed for self-administration of medication. During the initial tour, surveyors observed a box of fluticasone propionate nasal spray on Resident 13’s bedside table. An LVN later verified the medication was at the bedside and stated the resident was allowed to have the nasal spray there, although she was not sure about the storage requirement. Resident 13 was admitted to the facility with capacity to participate in medical decision-making and was documented as cognitively intact with no impairment to upper extremities. The physician’s order directed fluticasone propionate 50 mcg, one spray in each nostril daily as needed for allergy relief, with unsupervised self-administration. The resident’s self-administration assessment showed approval to self-administer medications and that the resident may keep medications at bedside. During interview, an RN stated the resident was fully capable of self-administration and said the nasal spray could be kept at bedside, not in a locked box. The DON was informed of and acknowledged the findings.
Kitchen Employee Hand Hygiene and Sanitizer Testing Deficiencies
Penalty
Summary
The facility failed to ensure one of 12 kitchen employees, Dietary Aide 1, had the appropriate competency and skill set to perform daily kitchen duties. The report states that 127 residents received food prepared in the kitchen. Facility policy required proper hand hygiene upon entering the kitchen and after handling soiled equipment or utensils, and required separate hand-washing facilities because kitchen sinks were not to be used for hand washing. Dietary Aide 1’s employee file showed he was responsible for maintaining a safe and sanitary work environment and that he met standards for hand hygiene and proper kitchen sanitation. During observation of the dishwashing process, Dietary Aide 1 loaded soiled dishes while wearing gloves, removed the gloves, rinsed his hands in the manual ware washing sink, and then picked up clean dishes from the clean side of the dishwashing machine. Later, when he entered the kitchen, he used hand sanitizer instead of washing his hands in the hand-washing sink before returning to work. The DSS confirmed that kitchen employees must wash their hands when entering the kitchen and that sanitizer is not to be used in place of handwashing. The facility also could not provide evidence that Dietary Aide 1 attended in-service training on testing the sanitizing solution. During observation, he tested the quaternary sanitizing solution in the red bucket incorrectly by dipping the test strip for three seconds, then again for two seconds, and the strip read less than 200 ppm both times.
Vegetarian Diet Meal Provided With Less Protein Than Regular Meal
Penalty
Summary
The facility failed to ensure that Resident 133, who had a physician-prescribed Regular Vegetarian diet, received a vegetarian meal with the same amount of protein as the regular diet. Facility records showed that the regular lunch meal included taco casserole, and the recipe and nutrition information for the ground beef, shredded cheese, and pinto beans used in that dish showed 16 grams of protein per serving. At the same meal, Resident 133 was observed receiving one veggie patty, mashed potatoes, seasoned zucchini, fiesta salad, and tangy glazed fresh fruit, and the nutrition information for the veggie patty showed 7 grams of protein. Interviews with the DSS and RD 2 showed the vegetarian diet was not being followed from the cooks spreadsheet and that the RD was not involved in ensuring the resident's nutritional needs were met for the vegetarian diet. The DSS stated residents on vegetarian diets were given a paper to tell CNAs what they wanted to eat, and that tofu or a veggie patty would be served as the entree. RD 2 stated she was not aware the facility had a vegetarian menu and later reported that RD 1 said nutritional needs for residents on vegetarian diets were met by providing supplements such as Boost or Pro-Stat. However, Resident 133's nutritional assessment completed by RD 1 documented a regular diet, with no documentation showing the resident was on a vegetarian diet and no recommendation for nutritional or protein supplements.
Failure to Educate Visitors and Staff on Safe Handling of Food Brought From Outside
Penalty
Summary
The facility failed to ensure that visitors who brought food from outside for residents, and staff who handled that food, were educated on safe food handling practices. The facility’s policy titled "Food Brought by Visitors" dated 2022 stated that staff were to assist family and visitors in understanding safe food handling practices, including safe cooling and reheating processes, hot and cold holding temperatures, preventing cross contamination, and hand hygiene. During an interview, Resident 133’s family member stated he brought ethnic food from his church to the resident every day. The food was stored in a previously used plastic butter container and three additional plastic containers, and Resident 133 was eating the food brought from outside. Resident 133’s husband stated he had not received any information from the facility regarding safe food handling practices. The DON stated the facility reviewed the rules on the policy with residents and visitors, but nothing in writing was given to them regarding safe food handling. The DSD confirmed she had not given staff an in-service regarding safe food handling.
Failure to Label and Document Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property from loss or theft by not ensuring that the resident's belongings were labeled with her name and included in her inventory list. During an observation and interview, the resident was found to have several valuable items in her room, such as a laptop, bluetooth headphones, a lap desk, and a music box, none of which were labeled or documented in her inventory. The resident stated she had informed staff whenever new items were brought in and had provided a list to the social services department, as instructed by nursing staff. A review of the resident's inventory form showed it had not been updated since her admission, and did not reflect the current belongings in her possession. Staff interviews confirmed that the inventory list was not updated to include the new items, and that the resident's personal property was not labeled. Staff acknowledged that the process for updating the inventory was not followed, despite being aware that the resident had accumulated many belongings over her long-term stay. The facility's policy required staff to label residents' belongings, update the inventory list when new items were brought in, and review the inventory for accuracy during quarterly care plan conferences. However, documentation from the most recent care plan meeting did not show that the inventory was discussed or updated. Multiple staff members, including CNAs, LVNs, the social services director, and the ADON, verified that the inventory list was outdated and that the resident's property was not properly labeled or recorded.
Failure to Suspend Staff Pending Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse prevention and management policy for one resident who alleged emotional distress caused by two nurses. According to the facility's policy, any employee accused of abuse must be immediately removed from resident care and suspended pending the outcome of the investigation. However, after a resident reported that two nurses had yelled at him and caused emotional distress, the facility did not suspend the identified nurses during the investigation period. Both nurses confirmed in interviews that they were aware of the allegations but were not suspended while the investigation was ongoing. The investigation was initiated after the resident's report and concluded a few days later, ultimately finding the claim unsubstantiated. Despite this, the facility's own documentation and staff interviews confirmed that the required suspension of the accused staff did not occur. The administrator acknowledged that the policy required suspension but chose not to follow it based on his own assessment of the situation, rather than adhering to the written procedures. The resident involved was able to make his needs known but was not able to make medical decisions independently.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that four residents were properly assessed and authorized to self-administer medications, as required by facility policy. During observations, surveyors found that these residents had various medications, including Refresh eye drops, Biofreeze pain relief cream, Bactine Max pain-relieving spray, and other topical pain relievers, stored at their bedsides or in nightstand drawers. Each resident reported self-administering these medications without prior assessment or approval from the interdisciplinary team (IDT) or the attending physician. Medical record reviews for each resident revealed the absence of required documentation, including assessments for self-administration capability, physician's orders permitting self-administration, and care plan entries addressing the self-administration of medications. In addition, there were no physician's orders for the medications themselves in the residents' records. Interviews with nursing staff confirmed that the facility's process was not followed, as none of the residents had been evaluated for their ability to safely self-administer medications, nor had the necessary approvals or documentation been obtained. The facility's policy mandates that residents may only self-administer medications after a licensed nurse completes an assessment, the IDT and attending physician approve, and a written order is obtained. The policy also requires that self-administration be documented in the care plan and medication administration record (MAR). These steps were not completed for the four residents involved, resulting in a failure to ensure safe self-administration of medications.
Failure to Provide Properly Fitted Incontinence Products
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not providing a properly fitted diaper. The resident, who is cognitively intact with a BIMS score of 14, is always incontinent of bladder and bowel, stands 68 inches tall, and weighs 405 lbs. During an observation and interview, the resident reported that the current diaper was too small, did not fit properly, and resulted in her bed being soaked multiple times a day. The resident also stated she had requested a properly fitting diaper for two weeks without resolution and expressed emotional distress over the situation. A CNA confirmed that the resident previously wore a 6x size diaper but was recently provided with smaller 4x or 5x sizes, which did not adequately cover the required area. The Central Supply In-charge explained that the facility's vendor no longer supplied the preferred Prevail diaper brand and had substituted it with a different, supposedly comparable size. The DON acknowledged the findings and confirmed the unavailability of the preferred diaper from the vendor.
Failure to Implement Bilateral Floor Mats for Fall Risk Resident
Penalty
Summary
A deficiency was identified when the facility failed to fully implement a comprehensive care plan intervention for a resident at risk for falls. The resident, who had dementia, impaired cognition, poor safety awareness, and a documented history of ongoing falls, had a care plan in place that required bilateral floor mats to be positioned on both sides of the bed as a fall prevention measure. Medical record review confirmed this intervention was part of the resident's care plan. Multiple observations conducted on the same day revealed that only one floor mat was consistently in place on one side of the resident's bed, while the opposite side lacked a floor mat. This was verified during an interview with an LVN, who acknowledged the absence of the second floor mat and confirmed that the care plan called for bilateral mats. The failure to implement this intervention as specified in the care plan constituted the deficiency.
Failure to Monitor IV Antibiotic Reactions and Document Code Status
Penalty
Summary
The facility failed to provide necessary care and services for two residents in the areas of IV antibiotic monitoring and advance directives. For one resident who was receiving IV antibiotics for an ESBL-positive urinary tract infection, there was no documented evidence of continued monitoring for adverse reactions to the medication or for worsening symptoms of the infection. Facility policy required licensed nurses to assess and document the resident’s condition every shift during the course of IV antibiotic therapy, but this was not done. Interviews with nursing staff confirmed that such monitoring and documentation were expected but not completed. For another resident with severe cognitive impairment who was on hospice services, the facility failed to clearly identify and communicate the resident’s current code status. The resident’s POLST form in the hospice binder was blank, and there was no physician’s order or care plan entry reflecting the code status. Although a scanned POLST indicating DNR status was found in the electronic health record, this information was not readily accessible or reflected in other key documentation. Nursing staff were unable to immediately determine the resident’s code status and stated that, in the absence of clear documentation, they would default to providing full code interventions. These deficiencies were identified through observation, interviews, and medical record review, and were acknowledged by facility staff. The lack of proper monitoring and documentation had the potential to result in residents not receiving care and services in accordance with their needs and treatment preferences.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with severe cognitive impairment and a diagnosis of dementia was observed wandering the unit, expressing a desire to go home, and was later found to have left the facility premises undetected. Despite documented episodes of wandering and confusion, the resident's care plan was not updated to address the increased risk of elopement, and staff were not informed of the need for enhanced supervision or specific interventions prior to the incident. Another resident, identified as being at risk for falls due to dementia, impaired cognition, and poor safety awareness, had a physician's order for bilateral floor mats as a safety intervention. However, during multiple observations, only one floor mat was in place, with the other side of the bed lacking the required mat. This was confirmed by staff, who acknowledged the omission and indicated that the second mat would be implemented in accordance with the physician's order. The facility's policies and procedures required assessment and care planning for elopement risk and resident safety upon admission, quarterly, and with any change in condition. In both cases, the facility did not follow its own protocols for reassessment and implementation of necessary safety interventions, resulting in residents being exposed to accident hazards and inadequate supervision.
Failure to Appropriately Assess and Monitor Dialysis Access Site
Penalty
Summary
The facility failed to ensure appropriate and consistent assessment and monitoring of a resident's dialysis access site. According to the facility's policy and physician's orders, the resident's arteriovenous (AV) shunt in the right arm was to be assessed for bruit and thrill every shift, with documentation of the findings and immediate physician notification if either was absent. Medical record review revealed multiple instances where the AV shunt was documented as negative, zero, or X for thrill and bruit, indicating absence, but there was no evidence that the physician was notified as required. Additionally, some documentation used 'NA' without clear understanding among staff of its meaning in this context. Interviews with licensed staff and the assistant director of nursing confirmed that the negative, zero, and X notations indicated absence of thrill and bruit, and that the physician should have been notified immediately in such cases. The staff acknowledged that the dialysis access site was not properly assessed and that the required notifications were not made. The resident involved had end-stage renal disease (ESRD) and received dialysis three times a week, with a care plan in place to monitor for complications related to dialysis, but the facility did not follow the established protocols for monitoring and response.
Failure to Prevent Unnecessary Side Rail Use for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident assessed as not needing side rails was not provided with them. Despite a completed Bed Rail Assessment indicating that side rails were not indicated, the resident was observed on multiple occasions with bilateral upper half side rails elevated. The resident's plan of care addressed the use of grab bars rather than side rails, and the medical record included a physician's order for bilateral half side rails as enablers. The facility's policy required a Bed Rail Evaluation prior to installation or use of any bed rail, but this process was not followed as documented in the assessment. The resident in question had severe cognitive impairment and was dependent on staff for bed mobility. The bed, which included the side rails, was brought into the facility with the resident, who was under hospice care. Staff verified that the side rails were not indicated according to the assessment, yet the rails remained in use, and the care plan did not address their presence. These actions and omissions resulted in the resident being exposed to accident hazards related to side rail use.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation of controlled medication administration for one resident. According to the facility's policy and procedure, licensed nurses are required to chart the drug, time administered, and initial their name with each medication administration, and record the time and dose in the patient's individual medication record. For one resident, there was a physician's order for hydrocodone-acetaminophen to be administered as needed for severe pain. The resident's individual narcotic record showed that the medication was dispensed and signed out on two occasions. However, a review of the resident's Medication Administration Records (MARs) for the relevant months did not show documentation of the administration of the hydrocodone-acetaminophen for the two instances when it was dispensed. Both an LVN and the DON verified that the required documentation was missing from the MARs, confirming that the facility did not follow its own policy for documenting the administration of controlled medications.
Failure to Properly Store and Dispose of Medications and Supplies
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored and disposed of according to professional standards and facility policy. During an inspection of a treatment cart, expired culture swabs and Allevyn Classic Adhesive dressings were found in the cart, and the LVN confirmed these items were expired and should have been discarded. The Director of Nursing (DON) was informed and acknowledged the presence of these expired supplies in the treatment cart. Additionally, a resident was observed with a sealed, unopened container of Wallgreens Redness Relief eye drops at their bedside. The resident stated they had purchased the eye drops while out on a pass, and the LVN verified the presence of the medication at the bedside, stating that medications should not be kept there. Review of the resident's medical record showed no physician order for the eye drops, and the resident was assessed as having moderately impaired cognition. The DON was made aware and acknowledged this finding.
Failure to Follow Chef Salad Recipe for Resident on NAS Diet
Penalty
Summary
The facility failed to follow the established recipe for chef salad when preparing a meal for one resident. The resident, who was on a no added salt (NAS) diet with regular texture and consistency, had a care plan goal to maintain weight status and had specific dietary preferences and dislikes documented. Despite these orders and preferences, the resident received a salad consisting only of lettuce, shredded carrots, and purple cabbage, without the required protein components such as turkey, ham, cheese, or hard-cooked eggs as specified in the facility's chef salad recipe. The resident expressed disappointment at not receiving enough protein with her salad, which she had been ordering more frequently in an effort to lose weight for an upcoming knee surgery. Review of the resident's meal card confirmed her dietary restrictions and preferences, including a request for chef salad with ranch dressing only. The Dietary Supervisor and Administrator acknowledged upon review that the chef salad was not prepared according to the recipe. This failure to follow the menu and recipe had the potential to result in the resident not receiving adequate nutrition as per her diet orders.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and a contracted, weak left hand was not provided with the required adaptive eating equipment as ordered by the physician. Observations during meal times showed the resident using regular utensils instead of the prescribed built-up utensils and lip plate, despite documentation in the care plan and meal tab indicating the need for these assistive devices. The facility's policy stated that adaptive equipment recommended by occupational therapy should be provided and consistently placed on the resident's tray. Interviews with staff confirmed the resident's need for built-up utensils due to limited hand strength and verified that the physician's order for these devices was in place. The resident reported difficulty using standard utensils, and staff acknowledged the importance of the adaptive equipment for the resident's ability to eat. The deficiency was further substantiated by a review of the resident's medical record, which documented the need for built-up utensils and a lip plate with all meals.
Failure to Follow Kitchen Infection Control and Food Storage Policies
Penalty
Summary
The facility failed to ensure that staff adhered to infection control and food storage policies in the kitchen. During an observation, the Dietary Services Supervisor (DSS) was seen inside the kitchen preparing breakfast without wearing a required hair restraint, despite having a beard and mustache. The DSS confirmed that he should have been wearing a hair restraint in accordance with the facility's policy, which mandates clean hair to be covered with an effective restraint in all kitchen and food storage areas. Additionally, a canister containing brown rice was found in the dry storage room without a lid, contrary to the facility's policy that requires opened dry storage products to be placed in containers with tight-fitting lids. Both the Cook and the DSS acknowledged that the canister should have had a lid to maintain cleanliness and infection control. These observations were made while the kitchen was preparing food for 123 residents, as indicated by the facility's diet count.
Failure to Ensure Provision and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure the provision and documentation of hospice services for two residents who were admitted to hospice care. For one resident, there was a physician's order and care plan specifying that a certified hospice aide should provide care twice per week. However, the medical record and hospice sign-in sheets showed missing documentation for several scheduled visits, with some weeks lacking any evidence that the hospice aide provided care. There was also no documentation that the facility coordinated with the hospice provider regarding these missed visits. For the second resident, the facility did not clarify or document the frequency of hospice agency staff visits, including those by the certified hospice aide, skilled nursing, social services, and chaplain. The hospice binder for this resident contained multiple blank and unsigned forms, including the POLST and various consent and notification documents. The medical record lacked evidence of certified hospice aide visits for two months, and the hospice calendar and flowsheet only reflected visits from the MSW and RN, with no documentation of aide visits. Interviews with facility and hospice staff confirmed the absence of required documentation and the lack of clarity regarding visit schedules. The DON, who served as the hospice coordinator, verified that the necessary forms were incomplete and that visit frequencies were not documented in the physician's order or care plan. These failures resulted in incomplete records and a lack of assurance that hospice services were provided as ordered.
Failure to Conduct Bed Entrapment Assessment for Resident Using Side Rails
Penalty
Summary
The facility failed to ensure that a bed inspection and entrapment assessment were conducted for one resident who was using bilateral upper side rails. The resident, who had severe cognitive impairment and was dependent on staff for bed mobility, was observed multiple times with the side rails elevated. Although the facility's policy required entrapment assessments upon admission, readmission, or a change of bed or mattress, there was no documented evidence that such an assessment was completed prior to the installation of the side rails for this resident. The resident's bed had been brought into the facility with the side rails already installed, and staff interviews confirmed that the maintenance department was not notified about the bed or the need for an entrapment assessment. Review of facility logs, including the Bed Side Rails Inspection Log and the Bed Entrapment Risk Checklist for the relevant month, showed no record that the resident's bed was inspected or assessed for entrapment risk. The maintenance staff stated that they were responsible for monthly bed inspections and entrapment assessments but had not been informed about this particular bed. Both the Maintenance Director and Maintenance Assistant verified that the resident's bed was not included in their inspection or assessment records.
Failure to Implement Infection Control Measures and Maintain Laundry Cleanliness
Penalty
Summary
The facility failed to maintain its infection prevention and control program as required, specifically by not implementing the testing, monitoring, and establishment of acceptable ranges for disinfectant chemical levels throughout the facility's water supply. Despite having a policy and procedure for water management and a plan for Legionella control, the facility had not begun the required testing and monitoring of chlorine and chloramine levels in the water system. The Infection Preventionist confirmed that this process had not yet started, and acceptable ranges for these chemicals had not been established at the time of the survey. Additionally, the facility did not maintain the laundry room and equipment in a clean and sanitary condition. Observations revealed that the outside of a washing machine door and its pipes had significant brown stains and white mineral-like residue, and the wall next to the machine was damaged with cracks and a gap between the wall and baseboard. The Housekeeping Supervisor acknowledged these findings during the inspection.
Failure to Implement Antibiotic Stewardship and Accurate Infection Control Documentation
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, resulting in multiple deficiencies related to infection control documentation and assessment. Specifically, the infection control data recorded in the surveillance log for January 2025 did not match the information documented in the Infection Control Report for the same period. The Infection Preventionist (IP) confirmed that these discrepancies affected the infection control process, staff education, and discussions in QAPI meetings. Additionally, the facility's mapping for healthcare-associated infections (HAI) was incomplete, as one resident with an eye/ear infection was not included in the mapping for January 2025. The facility was unable to provide documentation showing the use of McGeer's criteria to determine if residents met the criteria for true infection. The IP stated that she referenced the long version of the McGeer's form but could not produce documentation to support this. The Infection Screening Evaluation form used by the facility was inconsistent with McGeer's criteria, particularly for gastrointestinal tract infections, and did not clearly indicate how the criteria were met or not met. The IP acknowledged these inconsistencies and the lack of clear documentation. A review of the medical record for a resident revealed further issues with the assessment and documentation of infection. The resident was prescribed Ampicillin for symptoms of diarrhea, with the Infection Screening Evaluation indicating that McGeer's criteria for gastroenteritis were met. However, the surveillance log and progress notes stated that the resident did not meet McGeer's criteria. Despite this, the antibiotic was continued as ordered. The DON confirmed these findings, highlighting inconsistencies in the assessment and documentation process for antibiotic use.
Inaccurate MDS Coding for Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident. Medical record review showed that the resident was admitted with the capacity to understand and make decisions and had a physician's order to be discharged home with hospice services, as requested by the resident and their power of attorney. However, the Discharge MDS was incorrectly coded to indicate discharge to a short-term general hospital instead of to home with hospice. The MDS Coordinator confirmed that the MDS Assistant had coded the discharge status incorrectly, and the Director of Nursing acknowledged the findings during interviews.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to accurately maintain medical records for three residents. For two residents, review of their Physician Orders for Life-Sustaining Treatment (POLST) forms revealed that Section D, which pertains to advance directives, did not contain documentation indicating whether the residents had formulated an advance directive. This omission was confirmed during interviews and concurrent record reviews with a licensed vocational nurse, who acknowledged the missing information in both cases. Additionally, during a medical record review for another resident, it was discovered that the medical records of two other residents had been incorrectly filed within this resident's chart. This error was verified by a registered nurse during the review, who confirmed that the records were misplaced and subsequently removed them from the incorrect file.
Improper Storage of Garbage in Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage in two out of six dumpsters, as observed during a facility inspection. The lids of these dumpsters were found open, with garbage inside preventing the lids from fully closing. This condition was directly observed and verified by the Administrator through photographic evidence. The 2022 FDA Food Code requires outside garbage receptacles to have tight-fitting lids or covers to prevent the scattering of garbage, breeding of flies, or entry of rodents. The improper storage of garbage was attributed to the dumpsters being propped open by the accumulated refuse inside. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Care Plan Revision Deficiency for Wound Management
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was revised to reflect the current wound care treatment and interventions for each individual wound site. Specifically, the care plan did not include goals and interventions for the resident's left foot first metatarsal head and base arterial wounds, despite having a physician's order for treatment. This oversight was identified during a review of the resident's medical records, which showed that the care plan included other wound sites but omitted the left foot arterial wounds. The deficiency was confirmed during an interview and medical record review with the Director of Nursing (DON), who acknowledged that the care plan should have been updated to include all wound sites currently undergoing treatment. The resident had multiple wounds requiring specific care, including pressure injuries and skin tears, but the omission of the left foot arterial wounds from the care plan posed a risk of not providing individualized and person-centered care.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to provide necessary tube feeding care and services for a resident, identified as Resident 3, who was receiving enteral feeding via a PEG tube. The facility's policy required the head of the bed to be elevated 30 to 45 degrees during enteral feedings to prevent complications. However, during an observation on November 6, 2024, Resident 3 was found lying flat in bed while receiving Jevity 1.5 at 50 ml per hour through a feeding pump. This observation was confirmed by LVN 3, who acknowledged that the head of the bed should have been elevated to prevent the risk of aspiration. The Director of Nursing also acknowledged the finding later that day.
Inadequate PPE Use During High-Contact Care
Penalty
Summary
The facility failed to implement proper infection control practices, specifically in the use of personal protective equipment (PPE) during high-contact care activities for a resident. The deficiency was observed when a certified nursing assistant (CNA) handled a resident's Foley catheter without donning gloves and a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy. This policy, aligned with CDC guidelines, mandates the use of PPE during activities such as dressing, bathing, transferring, and device care to prevent the transmission of multidrug-resistant organisms (MDROs). The resident involved had a PEG tube, Foley catheter, and wounds, necessitating EBP. Despite the presence of signage indicating the need for PPE, the CNA did not adhere to these precautions. The incident was confirmed through interviews with the CNA, a registered nurse (RN), and the Director of Nursing (DON), all of whom acknowledged the requirement for PPE use during high-contact care activities to prevent infection transmission.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure proper storage of medications for a nonsampled resident, identified as Resident E. During a facility tour, a bubble pack containing potassium chloride extended release 20 mEq, labeled with Resident E's name, was found on the nursing station counter. This medication was prescribed as a potassium supplement to be taken in the morning. A Licensed Vocational Nurse (LVN) confirmed the medication belonged to Resident E and acknowledged it should have been stored inside the medication cart. The Assistant Director of Nursing (ADON) was informed of the situation and took possession of the medication.
Failure to Inventory Resident's Personal Property
Penalty
Summary
The facility failed to conduct an inventory of a resident's personal property in accordance with its policies and procedures, leading to a potential risk of loss or theft of the resident's belongings. Upon admission, the facility's policy required that a personal property inventory be conducted and documented in the resident's medical record. However, for Resident 2, there was no documentation of such an inventory being conducted at the time of admission. This oversight meant that there was no official record of the personal items the resident brought into the facility. When Resident 2 was transferred to an acute care hospital and later returned to the facility to collect his belongings, he discovered that several personal items were missing. Despite informing the social worker about the missing items, the resident did not receive a follow-up regarding the issue. The social worker confirmed that she assisted the resident in retrieving some items but did not document the inventory of the personal property released to the resident, as it was not part of her duties. The Director of Nursing (DON) confirmed that the facility's policy required documentation of personal property upon both admission and discharge, with signatures from both the resident and staff. However, the DON acknowledged that Resident 2's medical record lacked any documentation of his personal property, making it impossible to verify what items were brought in or released. This failure to adhere to the facility's policy resulted in an inability to account for the resident's belongings, highlighting a deficiency in safeguarding resident property.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policies and procedures related to abuse reporting for one of the sampled residents. The Activities Assistant did not report an abuse allegation to the Administrator when a resident informed her that a CNA was mad and threw towels on the resident's bed. This failure had the potential for the abuse allegation not to be investigated thoroughly, posing a risk of not providing appropriate actions to prevent further abuse. The resident, who had the capacity to understand and make decisions, reported feeling humiliated after an incident where a CNA threw towels at her and instructed her to dry herself without assistance. The Activities Assistant documented some of the resident's allegations but failed to report the specific incident of the CNA throwing towels on the bed to the Administrator. The Administrator was unaware of these allegations, acknowledging that all allegations of abuse should be reported to him.
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 6,525 citations issued within 25 miles in the last 12 months — including the 14 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) |
|---|---|---|---|---|
| Park Anaheim Healthcare Center | 0 mi | ★★★★★ | 28 | 0 |
| Anaheim Crest Nursing Center | 0.8 mi | ★★★★★ | 30 | 0 |
| West Anaheim Medical Center D/p Snf | 0.8 mi | ★★★★★ | 16 | 0 |
| Anaheim Terrace Care Center | 0.9 mi | ★★★★★ | 22 | 0 |
| Beach Creek Post-acute | 1.2 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Anaheim Point.
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.