Average — CMS composite of the measures below.
The next survey window likely opens around June 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 Terrace Care Center during CMS and state inspections, most recent first.
Failure to Follow Medication Orders and Rotate Insulin Sites: A resident’s ordered metoprolol was held even though BP and pulse were within parameters. Another resident had a BG of 466 mg/dL, received sliding-scale insulin, but the physician was not notified as ordered, and insulin injections were repeatedly given in the same sites instead of rotating. Three other residents also had repeated insulin administrations to the same arm or abdominal sites despite orders to rotate injection sites, and staff confirmed the orders were not followed.
A facility failed to manage pain as ordered for several residents by not documenting or providing nonpharmacological interventions before PRN analgesics and, in some cases, giving pain meds outside the ordered pain-scale parameters. Records showed repeated administrations of hydrocodone-acetaminophen, oxycodone-acetaminophen, morphine, and acetaminophen without required pain assessments or supporting documentation, and staff interviews confirmed the omissions.
Kitchen sanitation and food labeling deficiencies were identified during a kitchen tour and staff interviews. Surveyors observed three cutting boards that were fuzzy and heavily grooved, a toaster with dry food residue, crumbs, and rust inside, a utensil drawer with miscellaneous items, and a can opener blade with excessive wear. Two plates of salad in the refrigerator were also found without date labels, and dietary staff verified the findings.
The facility failed to maintain infection control practices during medication administration, water monitoring, and resident care. An RN did not perform hand hygiene before giving an IV medication, an LVN did not clean hands between oral and ophthalmic medication routes, and a CNA touched a soiled linen cart and then entered a resident’s room without hand hygiene. The facility also lacked consistent and accurate documentation for kitchen water temperature testing related to its Legionella and opportunistic pathogen water management program.
Failure to Provide Resident Representative for Incapacitated Resident: A resident who lacked capacity to make medical decisions was not provided a resident representative or public patient representative through OLTCPR. Records showed the IDT was listed as the legal decisionmaker, transfer documentation listed only the IDT, and multiple care conference records did not show representative participation. The SSD confirmed the facility did not involve a resident representative and did not contact OLTCPR, and the DON acknowledged the resident needed a representative for overall care.
A resident with decision-making capacity had psychotropic orders for escitalopram, buspirone, and PRN Ativan, but the informed consent documentation was incomplete. The disclosure forms for escitalopram and buspirone lacked the indication, manifested behavior, and nonpharmacological approaches, and both were missing the physician signature. The record also did not show informed consent for the renewed longer-duration Ativan order, and RN verification confirmed the missing documentation.
A resident had Visine eye drops on the nightstand and stated he was using them himself, but there was no physician order for the drops or for self-administration. The record also did not show an assessment that the resident was clinically appropriate and safe to self-administer medications, and an LVN confirmed the bottle was at the bedside and that no order existed.
A resident with capacity to understand and make decisions had an order for PRN Ativan 0.5 mg for anxiety manifested by constant screaming about having migraine headache. Facility policy required PRN psychotropic orders extended beyond 14 days to have physician documentation of the rationale and duration, but the record did not contain that justification. RN verified the order and could not locate the required documentation, and the DON acknowledged the finding.
Incomplete Transfer Documentation During Hospital Transfer: A resident was transferred to an acute care hospital for respiratory distress, but the transfer record was incomplete. The code status section was blank, the transfer checklist had no items marked to show what documents were sent, and the record did not show that required information such as the practitioner’s contact info, resident representative info, advance directives, or special instructions for ongoing care was communicated to the receiving provider.
PASRR Level II recommendations were not incorporated into a resident’s assessment and care plan. The resident had advanced dementia and cognitive impairment with no medical decision-making capacity, and the PASRR Level II determination identified SMI with multiple recommended services, including MH rehab activities, ADL training, supportive services, psychotherapy, psychiatry follow-up, safety and behavior monitors, pharmacy review, PT, OT, ST, dietary, and social services. Review of the care plan did not show these recommendations, and the MDS Coordinator could not produce an individualized plan reflecting them.
A resident with a GT, dysphagia, and no capacity for independent medical decisions did not receive the full ordered enteral feeding. The pump was found off during observation, and the feeding history showed 206 ml remaining, confirming the resident did not receive the prescribed Glucerna 1.2 dose. The DON stated nurses are expected to ensure the full physician-ordered amount is delivered.
Failure to Document Midline Catheter Measurements: A resident with a midline catheter for IV ceftriaxone had no documented external catheter length or arm circumference measurements upon admission or after dressing changes. RN verified the missing documentation, and the DON stated licensed nurses were expected to measure and document the catheter length and arm circumference to confirm placement.
Respiratory equipment care was not provided as required for two residents. A resident using CPAP and another using BiPAP stated staff had never cleaned the humidifier, headgear, tubing, or mask, and the records did not show the equipment was cleaned per facility policy. In addition, an oxygen cannula was found stored under a pillow instead of in a plastic bag when not in use, contrary to the facility’s infection prevention policy.
A resident receiving IV therapy through a PICC line was observed being flushed by an RN who left an air bubble in the NS syringe, and the RN acknowledged the error. The resident also had an IV vancomycin order for 1 gram/200 ml, but the facility administered 1 gram/250 ml instead; the RN, IV pharmacist, and DON all confirmed the medication on hand did not match the physician’s order.
Improper Disposal of Medications in Biohazard Container: Multiple whole, unidentified tablets were observed inside the biohazard container in Medication Room A during an observation with the DSD. The DSD confirmed the tablets should have been diluted and watered down after disposal to prevent inappropriate retrieval or use. The facility policy stated that outdated or deteriorated medications are to be disposed of according to medication disposal procedures.
A resident with hemodialysis and a right arm AV shunt had a physician order and care plan stating BP was not to be taken on the right arm, and the facility’s dialysis policy matched that instruction. However, the medical record showed multiple BP readings documented on the right arm. The resident and an LVN both confirmed the readings were inaccurate, and the DON was informed.
Glucometer Quality Control Testing Not Documented: The facility failed to ensure the glucometer on Medication Cart A was calibrated and that QC testing was performed and documented. Review of the EvenCare G2 QC log showed missed daily monitoring on several dates, and LVN 5 verified there was no documented evidence of calibration or low and high control solution testing. The DON stated nurses were expected to calibrate and perform QC checks to ensure accurate BG readings and appropriate insulin dosing as ordered.
A resident who experienced poor oral intake and low BP was not monitored every shift for at least 72 hours following a change in condition, as confirmed by medical record review and staff interviews. Required documentation of ongoing monitoring was missing for three consecutive shifts.
A resident's medical record, including essential discharge documentation, was incomplete and not accessible when requested. The facility was unable to provide the full record due to missing documentation and incomplete tracking logs for records stored offsite, resulting in a failure to demonstrate that proper discharge planning and teaching were provided.
Surveyors observed that food preparation equipment was stored wet, kitchen utensils and surfaces were not properly cleaned, and food items in the refrigerator were either unlabeled or past their use-by dates. The Dietary Services Supervisor confirmed these lapses, which affected the majority of residents receiving kitchen services.
Two residents were administered new or increased psychotropic medications without informed consent being obtained prior to administration. In one case, trazodone was given before consent was documented, and in another, quetiapine was administered at one dosage without any record of consent, despite the resident's cognitive impairment. Facility staff confirmed the absence of required consent documentation.
A resident was found with artificial tears eye drops at their bedside and attempted to self-administer the medication without a documented assessment or physician's order authorizing self-administration, as required by facility policy. Staff confirmed that the medication should not have been left at the bedside and that the necessary assessment was not completed.
A resident dependent on GT feeding experienced a significant change in condition, including abdominal distention and respiratory symptoms. Although a nurse obtained STAT orders for imaging, there was a delay in both performing the imaging and communicating the abnormal results—severe colonic distention and possible aspiration—to the physician. The physician was not notified until over seven hours after the facility received the reports, resulting in a delayed transfer to acute care. Facility policy requiring immediate physician notification for significant changes was not followed.
A resident with moderate cognitive impairment had a wallet in their possession that was not documented on the Inventory of Personal Effects form, as required by facility policy. Staff were aware of the wallet but failed to list it, which was discovered after the resident reported the wallet missing. The omission was confirmed by the SSD and an LVN, and acknowledged by the ADON.
Two residents receiving psychotropic medications were not properly monitored as required, with missing or incomplete documentation of orthostatic blood pressure and nonpharmacological interventions. Nursing staff failed to consistently implement or record non-drug interventions before administering medications, and PRN medications were sometimes given without proper justification. Facility leadership and clinical staff confirmed these lapses in required monitoring and documentation.
A resident discharged to an assisted living facility did not have documented evidence in their medical record of receiving the required written notice of discharge or discharge summary. Staff interviews confirmed that the discharge process should include these documents, but they were unable to provide proof that the resident received them as required by facility policy.
A resident was admitted with an anxiety disorder and later developed major depressive disorder and bipolar disorder, but the facility did not update the PASARR screening to reflect these new serious mental illness diagnoses. The ADON confirmed that the PASARR was not completed or referred as required after the new diagnoses, resulting in an inaccurate assessment of the resident's mental health needs.
The facility did not develop or implement comprehensive care plans for two residents with dementia and depressive symptoms, and failed to follow a fall prevention care plan for another resident, as required by physician orders and facility policy. These deficiencies were confirmed through record review, staff interviews, and direct observation.
A physician's order for weekly orthostatic BP monitoring, including while standing, was not completed for a resident who could not stand without assistance. The order was not clarified to match the resident's functional status, and the standing BP checks were not performed as required.
Two residents were not protected from accident hazards due to the facility's failure to implement bilateral floor mats as ordered by a physician for one resident at risk for falls, and failure to obtain a physician's order or care plan for another resident who repeatedly left the facility on pass. These lapses were confirmed through observation, record review, and staff interviews.
Three residents did not receive oxygen therapy as ordered by their physicians, with staff administering incorrect oxygen flow rates or failing to document the need for and administration of PRN oxygen. Staff confirmed that the oxygen provided did not match physician orders, and required documentation was missing from the medical records.
Three residents did not receive pain management in accordance with physician orders, as pain assessments were not consistently documented every shift, and pain medications were administered outside of the prescribed pain level parameters. Non-pharmacological interventions were also not documented prior to medication administration, contrary to facility policy and orders. Facility staff confirmed these deficiencies during interviews and record reviews.
Two residents receiving dialysis care experienced incomplete and inaccurate documentation of their dialysis treatments, including missing assessments of access sites and failure to record fluid intake as ordered. Additionally, blood pressure medications were not documented as administered after dialysis, despite physician orders. Facility leadership and nursing staff confirmed these deficiencies during interviews.
The facility did not ensure proper documentation and administration of controlled medications for two residents, as doses were removed from the supply but not recorded in the MAR. Additionally, a resident received blood pressure medication without required documentation of BP readings, and the medication was not held as ordered when BP exceeded specified parameters. The ADON confirmed these documentation and administration failures.
A licensed nurse failed to administer the full dose of zinc and vitamin D3 to a resident receiving medications via gastrostomy tube, leaving significant residue in medication cups. This resulted in a medication error rate of 5.13%, exceeding the acceptable threshold, as confirmed by staff interviews and direct observation.
Surveyors found that expired and discontinued medications were not removed from medication carts, some medications were not labeled with opened dates, and oral and external medications were stored together. Insulin and eye drops were kept beyond their discard dates, and medication storage areas were unsanitary. Nursing staff and leadership confirmed these practices did not follow facility policy.
A cook did not follow the prescribed recipe for pureed spaghetti by omitting margarine and non-fat dry milk powder while preparing meals for residents on a pureed diet. This deviation from the recipe was confirmed by both the cook and the Dietary Services Supervisor, and it affected several residents who required pureed food to meet their nutritional needs.
Surveyors found that food brought in by visitors for residents was not stored according to facility policy, with the residents' refrigerator observed at 70°F due to being overfilled and left partially open. Additionally, a food container was found without required labeling for date and use by date. Both an LVN and the ADON acknowledged these deficiencies in food storage and labeling practices.
Surveyors observed a large accumulation of unused items and refuse, including soiled bins, broken equipment, and trash, left in the facility compound. The Maintenance Director confirmed these items were not in use and should have been discarded, acknowledging that their presence could attract pests. Facility policies require daily removal of garbage and maintenance of litter-free grounds, but these procedures were not followed.
Multiple documentation errors were identified, including a resident's EHR containing another individual's PASRR screening, inaccurate MAR entries for two residents on apixaban, an incorrect psychiatric diagnosis listed for a resident, a POLST form indicating an advance directive that did not exist, and an incomplete discharge summary for a resident transferred to a hospital. These issues were confirmed by facility staff and leadership.
The facility did not provide documentation that its QAPI committee monitored the effectiveness of corrective actions for previously cited deficiencies related to informed consents, medication records, kitchen sanitation, and immunization status. Although specific audits and reviews were outlined in the plans of correction, there was no evidence that the QAPI committee evaluated or tracked the outcomes of these actions.
Staff were observed storing a resident's food items on the floor and leaving unlabeled basins in shared restrooms. LVNs and the ADON confirmed these practices did not meet infection control standards, as personal items and care equipment should be properly labeled and stored to maintain a sanitary environment.
A resident with decision-making capacity was not offered the annual influenza vaccine as required by facility policy, and there was no documentation of the offer or consent in the medical record. Interviews with the IP, ADON, and DSD confirmed the absence of required documentation and the expectation that the vaccine be offered and consent obtained each year.
A resident who had previously declined the COVID-19 vaccine was not offered the vaccine or informed consent again on an annual basis, as required by facility policy. Review of the medical record and staff interviews confirmed the absence of documentation showing that the vaccine was offered annually, and facility staff acknowledged this lapse.
The facility failed to provide necessary care for two residents, leading to deficiencies in their treatment. A resident experienced a delay in receiving Ciprodex Otic suspension for ear pain due to lack of follow-up by the LVN. Another resident did not receive the prescribed ceftriaxone sodium IV medication as there was missing documentation and the medication was not delivered by the pharmacy. The DON confirmed these issues, emphasizing the importance of proper documentation in the MAR.
A resident was not administered the correct probiotic as ordered, receiving acidophilus instead of the prescribed saccharomyces boulardii. Interviews with LVNs confirmed the discrepancy, and the DON acknowledged that the nurses should have clarified the order with the physician.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in equipment management. A resident's oxygen tubing was not changed weekly, and their CPAP mask was improperly stored. Another resident's suction equipment was not maintained according to policy, with dried secretions present. A third resident's oxygen tubing was improperly stored and not changed weekly. Staff confirmed these findings, indicating non-compliance with care orders.
A resident was found with medications in their bedside drawer without being assessed for self-administration, as required by facility policy. The resident placed the medications in the drawer after the nurse left, as they did not want to take them all at once. The DSD confirmed the need for an assessment and physician's order, while the LVN admitted to not staying with the resident until all medications were taken.
A resident with severe cognitive impairment exhibited aggressive behavior, hitting another resident, due to inadequate management and lack of a care plan. Despite previous aggressive incidents, the facility failed to notify the physician or implement interventions to prevent further harm. Staff interviews revealed a lack of communication and awareness about the resident's behavior, contributing to the incident.
A facility failed to promote the dignity and respect of a resident during meal assistance. A CNA was observed standing over a resident while feeding her in bed, which was confirmed during an interview. This action did not align with treating the resident with respect, highlighting a deficiency in upholding the resident's rights.
Failure to Follow Medication Orders and Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to provide treatment and care according to physician orders for multiple residents. For one resident with intact cognition, a physician ordered metoprolol 12.5 mg every 12 hours with instructions to hold only if systolic blood pressure was below 110 mmHg or pulse was below 55 beats per minute. On 7/6/26 at 0900, the resident’s blood pressure was 142/86 mmHg and pulse was 58 beats per minute, but the MAR did not show the medication was administered. During interview and record review, an LVN verified the medication had been held even though the resident’s vital signs were within the ordered parameters. For another resident with capacity to understand and make decisions, the physician ordered Humulin R sliding-scale insulin before meals and at bedtime, with instructions to notify the physician if blood sugar was below 70 mg/dL or above 400 mg/dL, and to rotate injection sites. The MAR showed a blood sugar of 466 mg/dL with 6 units of insulin given, but there was no documented evidence that the physician was notified. The same resident also had orders for Lantus Solostar with instructions to rotate injection sites, but the location records showed repeated injections in the same abdominal quadrant on multiple occasions. An RN verified that the physician should have been notified when the blood sugar exceeded 400 mg/dL and confirmed the injection sites were not being rotated as ordered. Three additional residents with capacity to understand and make decisions had insulin administration site rotation orders that were not followed. One resident receiving insulin glargine before breakfast and at bedtime had repeated administrations to the same sites, including the right lower quadrant, right arm, and left arm on consecutive administrations. Another resident receiving Novolog FlexPen before meals and at bedtime had repeated injections to the left arm on several administrations and then repeated injections to the right arm on later administrations. A third resident receiving Lantus SoloStar at bedtime and Humalog before meals and at bedtime had numerous administrations documented to the left arm over multiple days, with later administrations also documented to the right arm and then back to the left arm. Staff interviews confirmed the injection sites should have been rotated as ordered, and the DON acknowledged the findings.
Pain medication given without required assessment, nonpharmacological interventions, or ordered parameters
Penalty
Summary
The facility failed to provide necessary pain management care and services for six sampled residents who required pain treatment. The report states that the facility did not consistently provide or document nonpharmacological interventions before administering PRN pain medications, and in some cases administered pain medication outside the ordered pain-scale parameters. The facility’s pain management policy required individualized care planning, nonpharmacological and pharmacological approaches, documentation of interventions and effectiveness, and monitoring for effectiveness and side effects. For one resident, hydrocodone-acetaminophen was administered multiple times for severe pain, but the record did not show documented nonpharmacological interventions before those administrations. The resident’s orders included documentation of nonpharmacological interventions such as heat, repositioning, relaxation breathing, food or fluid, massage, exercise, immobilization of a joint, or other interventions. The record also showed one administration for a pain level of 3, which did not meet the ordered severe-pain parameters. A nurse and the DON acknowledged that the interventions were not documented as provided before the medication administrations. For another resident, hydrocodone-acetaminophen was administered repeatedly when pain levels were not assessed, and the record did not show nonpharmacological interventions before administration. The resident had orders for acetaminophen for mild pain, acetaminophen for moderate pain, and hydrocodone-acetaminophen for severe pain. The record showed multiple administrations of hydrocodone-acetaminophen without a documented pain assessment, and the DON acknowledged the findings. For a third resident, staff observed the resident in pain, but the staff did not offer nonpharmacological interventions before giving acetaminophen, and the medication was given for a pain level of 8 even though the order was for mild pain only. The nurse verified that the medication was administered outside the ordered parameter and that the physician was not notified. The remaining residents also had pain medication administered without documented nonpharmacological interventions before the doses were given. One resident received hydrocodone-acetaminophen on multiple occasions without documentation that nonpharmacological interventions were offered. Another resident received oxycodone-acetaminophen on multiple occasions without documentation that nonpharmacological interventions were offered. For another resident, hydrocodone-acetaminophen was given for pain levels that did not match the ordered medication parameters, and the record did not show nonpharmacological interventions before administration. In each case, staff interviews confirmed the lack of documentation or the failure to follow the ordered pain-management parameters.
Kitchen sanitation and food labeling deficiencies
Penalty
Summary
The facility failed to ensure sanitary conditions in the kitchen during an initial tour and concurrent interviews with dietary staff. Three cutting boards were observed to be fuzzy and heavily marred with grooves, and Dietary Aide 1 verified the finding. The report also noted a kitchen toaster stored on a countertop shelf that was dirty with dry food residue, crumbs, and rust inside, along with a utensil drawer containing miscellaneous items including paper and a pen. In addition, a can opener blade was observed to have excessive wear, and Dietary Aide 1 verified these findings as well. The facility also failed to ensure proper food labeling and dating in the refrigerator. Two plates of salad were observed stored without date labels, and Dietary Aide 1 stated that food must be dated when prepared. The DSS later verified and acknowledged the findings, and the Administrator and DON were informed and acknowledged them. The report states that 89 of 94 residents were receiving food prepared in the facility's kitchen.
Infection Control Lapses During Medication Administration, Water Monitoring, and Resident Care
Penalty
Summary
The facility failed to maintain infection control practices during medication administration and resident care. During an IV medication administration observation for one resident, an RN prepared the IV medication, donned gloves and a gown, and was not observed performing hand hygiene before administering the medication. During a separate medication administration observation for another resident, an LVN administered oral medications and then ophthalmic drops without performing hand hygiene between the two routes. The facility’s policies for handwashing and medication administration stated that hand hygiene is the primary means to prevent the spread of infections and that staff should follow infection control procedures, including handwashing and antiseptic techniques, during medication administration. The facility also failed to show consistent and accurate documentation of its water management testing protocols for Legionella and other opportunistic pathogens in the kitchen water temperatures for the entire month of February 2026. In addition, a CNA was observed touching a soiled linen cart and then entering a resident’s room to reposition the resident’s pillow without performing hand hygiene after touching the cart. The CNA verified the observation and stated she forgot to perform hand hygiene after touching the soiled linen cart and before assisting the resident.
Failure to Provide Resident Representative for Incapacitated Resident
Penalty
Summary
The facility failed to ensure Resident 6, who was unable to make her own decisions, was provided with a resident representative or a public resident representative through the Office of the Long-Term Care Patient Representative as required by AFL 23-18. Review of the resident’s H&P showed she had no capacity to understand and make decisions, and her Notification and Decision Making for Incapacitated Resident form showed she was informed of the right to have a resident representative participate in the IDT decision-making process and the right to judicial review of IDT decisions. Her POLST listed the facility’s IDT as her legal decisionmaker. Record review showed the Resident Representative Notified section of the SNF/NF to Hospital Transfer Form listed only the IDT, and the document did not show that the resident’s representative or a public resident representative from the OLTCPR was notified of the hospital transfer. Multiple Interdisciplinary Care Conference documents for care conference and psychotropic medication management failed to show documented evidence that a resident representative participated in the meetings. During interviews, the SSD verified the facility did not involve a resident representative in Resident 6’s care as required by AFL 23-18 and stated she did not contact the OLTCPR to obtain a public resident representative. The DON confirmed Resident 6 could not make her own medical decisions and stated a resident representative should have been present for her overall care.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure that Resident 9, who was documented in the H&P as having the capacity to understand and make decisions, was fully informed regarding psychotropic medications and that the required informed consent documentation was complete. The resident had physician orders for escitalopram 15 mg daily for depression as manifested by verbalization of feeling sad, buspirone 5 mg twice daily for anxiety as manifested by verbalization of feeling anxious, and Ativan 0.5 mg every 12 hours as needed for anxiety as manifested by constant screaming about having migraine headache. Review of the psychotropic medication administration disclosure for Ativan showed the resident was informed for the medication when it was ordered for 14 days, but the record did not show informed consent when the order was renewed for an extended 30-day duration. The MAR showed the resident received Ativan on multiple days after the 30-day order was entered. During the concurrent review, RN 1 verified the renewed Ativan order and was unable to find documentation showing informed consent was obtained for the 30-day order. The disclosure forms for buspirone and escitalopram did not include the indication of use, manifested behavior, or the list of possible nonpharmacological approaches that could address the resident's behavior related to the medications. In addition, both forms lacked a physician signature. RN 1 verified these omissions and was unable to find documentation showing the physician documented the discussion, the resident's understanding, or consent/refusal related to either medication. The DON was informed of and acknowledged the findings.
Unordered Eye Drops Found at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were safely administered for one resident when a bottle of Visine Red Eye Hydrating Comfort eye drops was found on the resident’s nightstand beside the bed. During the initial tour, the resident was observed lying in bed and stated that he instilled the eye drops himself. The facility’s policy stated that residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, with documentation in the medical record and care plan. Review of the resident’s Order Summary Report did not show a physician’s order for the Visine eye drops or an order allowing the resident to self-administer medications. Further review of the medical record did not show that the resident had been assessed for the ability to safely self-administer medications. When the issue was reviewed with an LVN, the LVN verified the eye drops were on the resident’s nightstand and confirmed there was no physician’s order for the eye drops or for self-administration. The DON was later informed and acknowledged the findings.
PRN Psychotropic Medication Extended Without Required Documentation
Penalty
Summary
The facility failed to ensure that one of five sampled residents reviewed for unnecessary medications was free from unnecessary psychotropic medication use. Resident 9, who was admitted to the facility and later readmitted, had an H&P dated 5/4/26 showing the resident had the capacity to understand and make decisions. A physician order dated 7/9/26 prescribed Ativan 0.5 mg, one tablet by mouth every 12 hours PRN for 30 days for anxiety as manifested by constant screaming about having migraine headache. Facility policy titled Psychotropic Medication Use stated that residents do not receive psychotropic drugs pursuant to a PRN order unless the medication is necessary to treat a diagnosed specific condition documented in the clinical record, and if a PRN order is extended beyond 14 days, the physician must document the rationale and duration in the medical record. Review of Resident 9's record did not show documentation from the physician justifying continued PRN Ativan use beyond 14 days. During a concurrent record review, RN1 verified the order and stated she could not locate documentation showing the required clinical justification for extending the PRN psychotropic medication beyond the regulatory limit. The DON was informed and acknowledged the findings.
Incomplete Transfer Documentation During Hospital Transfer
Penalty
Summary
The facility failed to ensure a safe and effective transition of care when Resident 102 was transferred to an acute care hospital for respiratory distress. The resident had a physician order dated 6/2/26 to transfer the resident to the hospital via 911, and the closed medical record showed the resident was transferred on that date. Review of the facility’s Transfer or Discharge policy showed that when a resident is transferred or discharged, appropriate information is to be documented in the medical record and communicated to the receiving health care institution or provider, including a summary of the resident’s overall medical, physical, and mental condition. Resident 102’s SNF/NF to Hospital Transfer Form had the code status section left blank. The Acute Care Transfer Document Checklist listed items that were recommended or required to accompany the resident, including the transfer form, face sheet, current medication list or MAR, SBAR/change in condition note, advance directives, advance care orders, and additional medical records, but no entries or check marks were made to show what was sent. The EMT and transport team signature section was also blank. The medical record did not show documentation that the required information, including the practitioner’s contact information, the resident’s representative information, advance directive information, or special instructions or precautions for ongoing care, was communicated to the receiving provider. RN 1 and the DON were interviewed and acknowledged that the documented evidence could not be found.
PASRR Level II recommendations were not incorporated into the resident’s care plan
Penalty
Summary
The facility failed to ensure that the recommendations from a PASRR Level II determination were incorporated into the assessment and care planning for one resident. The resident had been admitted and later readmitted to the facility, and the H&P dated 5/4/26 documented advanced dementia and cognitive impairment with lack of medical decision-making capacity. The PASRR Notice of Individual Determination dated 5/6/26 identified a Serious Mental Illness Level II determination and documented a medical and social history showing a significant medical condition with mental stressors requiring nursing care. The PASRR Level II determination recommended multiple specialized add-on services, including mental health rehabilitation activities, ADL training/reinforcement, supportive services, psychotherapy/counseling, psychiatry consultation and follow-up care, safety monitors, behavior monitors, pharmacy consultation, PT, OT, speech therapy, dietary consultation, social services consultation, and accessibility accommodations for alternative community placement settings. Review of the resident’s plan of care dated 5/6/26 did not show an individualized care plan incorporating these recommendations. During interview and concurrent record review, the MDS Coordinator was unable to show a care plan reflecting the PASRR Level II recommendations from the DHCS psychologist, and the Administrator and DON were informed and acknowledged the findings.
Incomplete GT Feeding Administration
Penalty
Summary
The facility failed to provide the necessary care and services related to GT feeding for one of three residents reviewed for tube feedings. Resident 48 had a feeding tube, a diagnosis of dysphagia, and lacked the capacity to make independent medical decisions. A physician’s order directed Glucerna 1.2 to be administered at 45 ml/hr for 20 hours to provide 900 ml/1080 kcal. During observation on 7/12/26, Resident 48 was seen in bed with Glucerna 1.2 hanging on the pole, and the feeding pump was observed in the off position. During a concurrent observation and interview, LVN 1 verified the pump was off and checked the pump history, which showed the feeding was incomplete with 206 ml left. LVN 1 verified that Resident 48 did not receive the prescribed 900 ml dose of enteral feeding. The DON later stated that licensed nurses are expected to ensure residents receiving enteral feeding receive the full amount prescribed by the physician and that failure to provide the full amount increased the risk of adverse outcomes, including weight loss.
Failure to Document Midline Catheter Measurements
Penalty
Summary
The facility failed to ensure proper monitoring of a resident’s midline catheter to the right upper arm. Resident 109 was admitted with a single-lumen midline catheter in the right brachial vein and had a BIMS score of 14, indicating intact cognition. The resident also had physician orders for IV ceftriaxone sodium for cellulitis of both lower extremities and for IV dressing changes that included documenting the external catheter length and upper arm circumference. Review of the medical record showed no documented evidence that the midline external catheter length or arm circumference was measured upon admission or after dressing changes. The resident’s midline catheter dressing was dated 7/11/26, and during an observation and concurrent record review, RN 1 verified there was no documentation of the external catheter length or arm circumference measurement on admission or after that dressing change. RN 1 stated the midline catheter and arm circumference should be measured and documented to assess placement. The DON stated licensed nurses were expected to measure the midline catheter length and arm circumference to ensure the midline was not dislodged and remained correctly placed, and that these assessments should occur upon admission and during dressing changes.
Respiratory Equipment Not Cleaned or Stored Properly
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for two residents who used CPAP/BiPAP equipment and, for one resident, oxygen. Resident 40, who had a BIMS score of 15 and a physician’s order to turn the CPAP on at bedtime and off in the morning, was observed with a CPAP machine on the nightstand and stated that staff had never cleaned the humidifier, headgear, tubing, or mask. Review of the medical record did not show documentation that the CPAP equipment was cleaned according to facility protocol. Resident 74, who had capacity to understand and make decisions, was observed using BiPAP with the oxygen nasal cannula placed underneath the pillow. The resident stated staff had never cleaned the BiPAP humidifier, headgear, tubing, or mask, and the medical record did not show documentation that the BiPAP equipment was cleaned according to facility protocol. The resident also had physician’s orders for oxygen via nasal cannula as needed and for BiPAP use as needed, and the facility’s infection prevention policy stated the oxygen cannula and tubing should be kept in a plastic bag when not in use; the IP verified the cannula was not stored that way.
Unsafe IV Medication Administration and Order Mismatch
Penalty
Summary
Pharmaceutical services were not safely provided for one resident who was receiving IV therapy through a right upper arm PICC line. During an observed medication administration, RN 1 flushed the PICC line with normal saline without removing an air bubble from the flush syringe. When interviewed, RN 1 stated she forgot to remove the air bubble and acknowledged that air entering a central line could cause an embolus leading to respiratory or cardiac arrest. The facility’s policy stated medications are to be administered safely and in accordance with prescriber orders. The resident had been admitted to the facility and had a physician’s order for central line flushes every 12 hours and an order for IV vancomycin 1 gram/200 ml for lower extremity cellulitis. The IV vancomycin available and administered was 1 gram/250 ml, which did not match the physician’s order. The contracted IV pharmacist stated the pharmacy did not dispense vancomycin 1 gram in 200 ml bags and that the facility should have clarified the order because the flow rate would differ. RN 1 confirmed the medication on hand did not match the order, and the DON acknowledged that the order should have been clarified before administration.
Improper Disposal of Medications in Biohazard Container
Penalty
Summary
The facility failed to store disposed drugs and biologicals in a safe manner. During an observation and concurrent interview in Medication Room A, multiple whole, unidentified tablets were seen inside the biohazard container used for medication disposal. The DSD confirmed the tablets were present and stated the disposed medication tablets should have been diluted and watered down after being placed in the biohazard container to prevent inappropriate retrieval or use. The facility's policy stated that outdated, contaminated, or deteriorated medications are to be disposed of according to medication disposal procedures, but the observed tablets remained whole in the disposal container.
Inaccurate Blood Pressure Documentation for Resident With Right Arm AV Shunt
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented when the resident’s blood pressure access site was recorded incorrectly. Resident 31 was admitted with a history of hemodialysis and renal insufficiency, had an AV shunt in the right arm, and had a physician order and care plan instructions stating that blood pressure was not to be taken on the right arm. The facility’s Dialysis Care policy also stated that blood pressure would not be taken on the arm with the shunt. Review of the resident’s documented blood pressure readings for June and July 2026 showed multiple entries recorded on the right arm, including readings on several different dates and times. During observation, the resident was seen sitting in a wheelchair with the AV shunt in the right arm. The resident stated that nurses were not allowed to take blood pressure on the right arm and verified it was never taken there. An LVN reviewed the record and confirmed the documented right-arm blood pressures were inaccurate, and the DON was informed of the findings.
Glucometer Quality Control Testing Not Documented
Penalty
Summary
The facility failed to ensure the glucometer on Medication Cart A was calibrated and that quality control testing was performed. Review of the facility’s Control Solution Testing document for the EvenCare G2 meter showed that control solution testing is used to verify that the meter and test strips are working properly, and that results are stored in meter memory and indicated by a ctl icon. The document also listed possible causes of an out-of-range control solution result, including use of the wrong control solution, control solution not at room temperature, expired or contaminated control solution, damaged test strips, or meter malfunction. Review of the EvenCare G2 Quality Control Log showed the glucometer was monitored daily except on several dates, including 7/2, 7/7, 7/11, 7/12, and one additional date. During an interview and concurrent document review with LVN 5, the glucometer did not show documented evidence that it was calibrated and that low and high control solution testing had been performed. LVN 5 stated glucometers should be calibrated and quality control testing should be performed to ensure accurate blood glucose readings for residents. The DON stated she expected nurses to calibrate and perform quality control checks for glucometers to ensure accurate blood glucose results and appropriate insulin dosing as ordered. The Administrator and DON acknowledged the findings.
Failure to Monitor Resident After Change in Condition
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain the highest practicable well-being for a resident who experienced a change in condition. Specifically, after the resident was observed to have poor oral intake and low blood pressure, there was no documented evidence that the resident's condition was monitored every shift for at least 72 hours as required. Medical record review showed gaps in monitoring during three consecutive shifts following the initial change in condition. Interviews with nursing staff confirmed that the resident's medical record did not contain documentation of shift-by-shift monitoring after the change in condition was identified. Staff acknowledged that residents with a change in condition should be monitored every shift for a minimum of 72 hours, and that this monitoring should be documented in the medical record. The lack of documentation indicated that the required monitoring was not performed or recorded as per facility protocol.
Incomplete and Inaccessible Medical Record for Discharged Resident
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for one of eight sampled residents. Specifically, the medical record for a resident who had been discharged was incomplete and not available upon request, as required by the facility's policies and procedures. The missing documentation included physician's orders, assessments, progress notes, and discharge planning information. This lack of documentation meant the facility could not demonstrate that appropriate discharge planning and teaching had been provided to the resident and their family member. Interviews with the Medical Records Director revealed that discharged residents' medical records were sent to an offsite storage company and were supposed to be retained for ten years. However, when the record was requested, it could not be located among the boxes received from storage, and the log used to track the location of stored records was incomplete and missing key information. As a result, the facility was unable to provide the required documentation for the resident's discharge, in violation of its own policies.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to follow food safety and sanitation guidelines in several key areas, as observed during a kitchen inspection and interviews with the Dietary Services Supervisor (DSS). Food preparation equipment, such as a red blender, was found stored while still wet, contrary to USDA Food Code requirements for air-drying to prevent microorganism growth. Additionally, kitchen equipment and utensils were not maintained in a sanitary condition: a red cutting board was heavily marred and had food residue, multiple red insulated plate bases were dusty, and two oven tray sheet pans had heavy dark brown residue. The DSS confirmed these items were ready for use and should have been properly cleaned or replaced. Further deficiencies were noted in the storage of food items. In the walk-in refrigerator, bins containing chopped strawberries and blueberries lacked date labels indicating when they were prepared, and 31 small cups of ranch dressing were found with expired use-by dates. The DSS acknowledged that all prepared, ready-to-eat food items should be labeled with preparation and use-by dates, and that expired items should be discarded. These failures were identified while 87 of 94 residents were receiving food from the kitchen.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering new or increased psychotropic medications for two residents. For one resident, trazodone was administered for depression before informed consent was obtained, as documented by a physician's order and a subsequent consent form completed after the medication had already been started. The Assistant Director of Nursing (ADON) confirmed that the medication was given prior to obtaining the required consent. For another resident with moderately impaired cognition and a diagnosis of schizoaffective disorder, quetiapine fumarate was ordered and administered in two different dosages. While informed consent was obtained for the 100 mg bedtime dose, there was no documentation of informed consent for the 50 mg daily dose, despite the medication being administered regularly. The ADON and Administrator both verified that the required consent for the 50 mg dose was not present in the medical record.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident was found with a bottle of artificial tears eye drops on their bedside table, which had been left there by a medication nurse three days prior. The resident attempted to self-administer the medication but was unable to do so. There was no documentation in the resident's medical record indicating that an assessment had been completed to determine if self-administration of medication was clinically appropriate or safe for the resident, as required by the facility's policy and procedure. The policy specifies that the interdisciplinary team (IDT) must assess a resident's cognitive and physical abilities before allowing self-administration of medication. Further review of the resident's medical record confirmed the absence of an assessment or a physician's order authorizing self-administration of the eye drops. Both a licensed vocational nurse (LVN) and the assistant director of nursing (ADON) verified that the medication should not have been kept at the bedside and acknowledged that the required assessment and order were missing. The resident had the capacity to make medical decisions, as documented in their history and physical examination, but the necessary steps to ensure safe self-administration were not followed.
Failure to Timely Notify Physician of Change in Condition and Abnormal Imaging Results
Penalty
Summary
The facility failed to ensure timely physician notification and intervention for a resident who experienced a significant change in condition. The resident, who was dependent on gastrostomy tube (GT) feeding, was observed with a distended abdomen and had a care plan in place requiring monitoring and reporting of symptoms such as aspiration, fever, shortness of breath, tube dislodgement, infection, abdominal pain, distention, and tenderness. On the day of the incident, the resident exhibited chest congestion, cough, and abdominal distention, prompting a licensed nurse to notify the physician and obtain orders for STAT chest x-ray, KUB, and labs. Despite these orders, there was a significant delay in both the completion of the imaging and the communication of the results to the physician. The radiology reports, which indicated severe colonic distention and possible aspiration or developing consolidation, were transmitted to the facility late at night. However, documentation showed that the physician was not notified of these critical findings until more than seven hours after the reports were received. Interviews with nursing staff revealed that attempts to contact the physician were either not made in a timely manner or not documented, and there was a lack of follow-up as required by facility policy when the physician could not be reached. The delay in notifying the physician and obtaining further orders resulted in a late transfer of the resident to an acute care hospital for evaluation and treatment. The facility's policy required immediate notification of the physician and resident representatives in the event of a significant change in condition, but this protocol was not followed. The deficiency was confirmed through observation, interviews, medical record review, and review of facility policies and procedures.
Failure to Safeguard Resident's Personal Property Due to Incomplete Inventory Documentation
Penalty
Summary
The facility failed to provide reasonable care for the protection of a resident's personal property, specifically by not listing the resident's wallet on the Inventory of Personal Effects form as required by facility policy. The policy states that all personal items brought into the facility must be documented on the inventory form, with signatures from the resident or their representative and a staff member. Despite this, the resident's wallet was not recorded, and both the Social Services Director (SSD) and an LVN confirmed that the wallet was in the resident's possession but not listed in the inventory. The resident involved had moderate cognitive impairment, as indicated by their MDS assessment. The omission was discovered after the resident reported his wallet missing, though it was subsequently found by staff. Interviews with the SSD and LVN revealed awareness of the resident's possession of the wallet, but both acknowledged that it should have been documented in the inventory to ensure proper safeguarding of the resident's belongings. The Assistant Director of Nursing (ADON) was informed and acknowledged these findings.
Failure to Monitor and Document Psychotropic Medication Use and Required Interventions
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications and that required monitoring and nonpharmacological interventions were implemented and documented as ordered. For one resident with moderately impaired cognition and diagnoses including schizoaffective disorder, depression, and anxiety, physician orders and care plans required regular monitoring of orthostatic blood pressure (BP) in multiple positions and the use of non-drug interventions prior to administering psychotropic medications such as quetiapine, aripiprazole, duloxetine, and lorazepam. However, medical record reviews revealed that orthostatic BP was not accurately or fully documented, with missing readings for required positions. Additionally, when behavioral episodes such as inconsolable screaming, anxiety, and disorganized speech were observed, the nonpharmacological interventions were either not attempted, not documented, or marked as 'not applicable' or '0', even when the behaviors were present and medications were administered. Further review of medication administration records showed that the resident received PRN lorazepam on multiple occasions without documentation of attempted or effective nonpharmacological interventions, and sometimes even when no behavioral episode was documented. Interviews with nursing staff and the ADON confirmed that the required interventions and documentation were not consistently completed, and that PRN medications were sometimes given despite documentation that nonpharmacological interventions were effective or not attempted at all. The ADON also verified that orthostatic BP monitoring was incomplete and not properly recorded in the resident's records. For a second resident, also with moderately impaired cognition and prescribed quetiapine for psychosis, physician orders and care plans required weekly orthostatic BP monitoring in different positions to detect potential orthostatic hypotension. However, medication administration records showed that BP readings were either identical across different positions or missing for some positions, indicating that the monitoring was not performed as ordered. The ADON confirmed that BP readings should differ between positions and acknowledged the incomplete documentation. Facility leadership was informed of these findings and acknowledged the deficiencies.
Failure to Provide Discharge Notice and Summary Documentation
Penalty
Summary
The facility failed to provide the required notice of discharge and discharge summary documentation for one of three sampled residents reviewed for closed records. Specifically, a resident who was admitted to the facility and later discharged to an assisted living facility did not have documented evidence in their medical record that they received the written notice of discharge or the discharge summary at the time of discharge. The facility's policy requires that such documentation be provided to the resident and/or their representative and included in the medical record. Interviews with facility staff, including the ADON and SSD, confirmed that the discharge process should include a transfer/discharge packet with the necessary documents, which are to be signed by the resident and documented in the medical record. However, both staff members were unable to produce evidence that these documents were completed or provided to the resident in question. The findings were acknowledged by the DSD and Administrator during the survey.
Failure to Update PASARR Following New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) process was accurate and updated for one resident. Upon admission, the resident had a diagnosis of anxiety disorder, and later developed additional diagnoses of major depressive disorder and bipolar disorder. The initial PASARR Level I Screening indicated that the resident did not have a serious mental illness, despite the presence of anxiety disorder at the time. The facility's policy required that all admissions have the appropriate PASARR completed and that state-specific guidelines be followed. Further review of the resident's medical record showed that no updated PASARR screening was completed when the resident was subsequently diagnosed with bipolar disorder and major depressive disorder after admission. During an interview, the ADON confirmed responsibility for ensuring PASARR accuracy and acknowledged that the screening should have been updated and referred accordingly when the new diagnoses were made. The failure to update the PASARR meant the resident's mental health status was not accurately reflected or reassessed as required.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents as required by its own policies and federal regulations. For one resident at risk for falls due to cognitive loss and lack of safety awareness, the care plan specified the use of bilateral floor mats. However, during multiple observations, only one floor mat was in place, and the other side of the bed was left without a mat, contrary to the care plan's interventions. This failure was confirmed by the Director of Staff Development (DSD) during an interview and observation. Additionally, the facility did not create care plans to address the use of dementia medications (Aricept and Namenda) for another resident, despite physician orders for these medications. The Assistant Director of Nursing (ADON) confirmed that a care plan should have been initiated for these medications but was missed. Another resident with documented depressive symptoms and ongoing psychological evaluation and treatment also lacked a care plan addressing these mental health needs. The ADON verified that the care plan problem for depressive signs and symptoms was not developed as required.
Failure to Clarify and Complete Orthostatic BP Monitoring Order
Penalty
Summary
A deficiency occurred when a physician's order for weekly orthostatic blood pressure (BP) monitoring while lying, sitting, and standing was not properly clarified or followed for one resident. The resident's medical record showed that the standing BP checks were not completed as ordered. During an interview and concurrent record review, the ADON confirmed that the resident was unable to stand without assistance from two staff members, making the standing BP check inappropriate for the resident's functional level. The physician's order was not clarified to reflect the resident's actual abilities, resulting in the order not being carried out as written.
Failure to Implement Fall Prevention Measures and Secure Physician Orders for Resident Passes
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards and that adequate supervision and physician oversight were provided. For one resident, a physician's order dated 10/25/24 required the use of bilateral floor mats due to the resident's risk for falls associated with cognitive loss and lack of safety awareness. However, multiple observations on 5/19/25 revealed that only one floor mat was in place at the bedside, contrary to the physician's order, and this was confirmed by the Director of Staff Development (DSD). For another resident, the facility did not obtain a physician's order prior to the resident going out on pass, as required by the facility's policy. Medical record review showed no such order or care plan allowing the resident to leave the facility unsupervised, despite documentation that the resident had left the facility for extended periods over several months. The Assistant Director of Nursing (ADON) confirmed that the resident frequently went out on pass and that there was no physician's order or care plan in place for these absences.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to three residents by not following physician orders for oxygen administration. For one resident, the oxygen concentrator was set at three liters per minute (LPM), but the nasal cannula was not in the resident's nose, and there was no documentation in the medical record or medication administration record (MAR) to indicate that oxygen was needed or administered as ordered. The resident's physician order specified oxygen at two LPM via nasal cannula as needed for shortness of breath, with titration to maintain oxygen saturation at or above 90%, and required documentation of administration and the reason for use. However, there was no evidence of shortness of breath, low oxygen saturation, or documentation of PRN oxygen administration in the records. Additionally, another resident was observed receiving six LPM of oxygen via nasal cannula, while the physician's order specified continuous oxygen at two LPM. A third resident was observed receiving five LPM of oxygen, despite a physician's order for three LPM. In both cases, staff verified that the oxygen being administered did not match the physician's orders. These discrepancies were confirmed through observation, staff interviews, and medical record reviews, indicating a failure to ensure that oxygen therapy was provided as prescribed.
Failure to Follow Pain Management Protocols and Documentation Requirements
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents by not following physician orders for pain assessment, documentation, and medication administration. For two residents, physician orders required pain to be monitored and documented every shift, but medical record reviews showed that pain assessments were not consistently performed or recorded as ordered. In several instances, pain levels were only documented sporadically, and there were gaps in the monitoring records for entire shifts. Additionally, pain medications were not administered according to the prescribed pain level parameters. One resident received acetaminophen for a pain level below the ordered threshold, and another resident was given hydrocodone-acetaminophen for pain levels that did not meet the criteria for severe pain as specified by the physician's order. These deviations from the prescribed medication protocols were verified by facility staff during interviews and record reviews. The facility also failed to ensure that non-pharmacological interventions were attempted and documented prior to administering pain medications, as required by both physician orders and facility policy. For one resident, there was no documentation of non-pharmacological pain interventions before medication administration, and staff confirmed that these interventions should have been implemented and recorded. The lack of adherence to pain management protocols and documentation requirements was acknowledged by the ADON, LVN, and other facility leadership during interviews.
Failure to Ensure Complete Dialysis Documentation and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring such services, as evidenced by incomplete and inaccurate documentation and failure to follow physician orders. For one resident, the Hemodialysis Communication Records were missing critical information such as documentation of the dialysis access site, swelling, drainage, pain, and whether there were new orders from the dialysis center. The records also showed inconsistencies regarding the type of access site being used, and there was a lack of documentation for required assessments like bruit and thrill. These omissions were verified by both nursing staff and the Assistant Director of Nursing (ADON), who confirmed that the records should have been completed accurately to ensure proper assessment and monitoring of the resident's condition before and after dialysis treatments. Another resident's care was similarly deficient, with Hemodialysis Communication Records missing documentation of post-dialysis assessments, including thrill, site type, swelling, drainage, pain, and post-hemodialysis complications. Additionally, the facility failed to accurately document and monitor the resident's fluid restriction as ordered by the physician. Instead of recording the actual fluid intake, staff marked the medication administration record (MAR) with an "X" each shift, and there was no documentation of fluid intake during meals by certified nursing assistants (CNAs). The ADON and nursing staff acknowledged that the fluid restriction was documented incorrectly and that there was no record of total fluid intake per meal. Furthermore, the facility did not ensure that blood pressure medications were administered to the resident after dialysis as per physician orders. On multiple occasions, the MAR indicated the resident was away for dialysis, but there was no documentation that the medications were given upon the resident's return, despite orders allowing for post-dialysis administration. The ADON confirmed the absence of documentation for these medications on the relevant dates. These failures were acknowledged by facility leadership during interviews and had the potential to prevent the identification of negative outcomes for residents receiving dialysis.
Failure to Document and Administer Medications per Physician Orders
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by discrepancies in the documentation and administration of controlled medications and blood pressure medication. For two residents, doses of controlled medications (tramadol and Norco) were removed from the supply as recorded in the controlled drug logs, but there was no corresponding documentation in the Medication Administration Records (MAR) to show that these medications were administered. The Assistant Director of Nursing (ADON) confirmed that the doses should have been documented in the MAR, and acknowledged the lack of documentation for these administrations. Additionally, for another resident, the facility did not follow physician orders regarding the administration of midodrine, a medication for low blood pressure. The physician's order specified that the medication should be held if the systolic blood pressure (SBP) was greater than 130 mmHg. However, the MAR showed that the medication was administered without documentation of blood pressure readings prior to administration, and on two occasions, the medication was given when the SBP exceeded the hold parameter. The ADON verified that there was no documentation of blood pressure readings prior to administration and that the medication should have been held based on the recorded blood pressure values.
Medication Error Rate Exceeds 5% Due to Incomplete Administration via GT
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 5.13%. During a medication administration observation, one licensed nurse (LVN 1) did not administer the complete dose of two medications—zinc and vitamin D3—to a resident receiving medications via a gastrostomy tube (GT). After administration, significant residue of these medications was found in the medication cups, indicating that the full prescribed doses were not delivered as ordered. The facility's policies and procedures require that medications be fully administered according to prescriber orders and that medications given via enteral tube be properly diluted and mixed to ensure complete dosing. Interviews with LVN 1, the Assistant Director of Nursing (ADON), and other facility leadership confirmed that the expected practice is to add water and thoroughly mix any medication residue to ensure the entire dose is administered. LVN 1 acknowledged the failure to do so during the observed medication pass. The incident involved a resident with multiple medical conditions, including diabetes, hypertension, and the need for enteral feeding, who was prescribed several medications and supplements. The incomplete administration of zinc and vitamin D3 was directly observed and verified by facility staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices across two medication rooms and three medication carts. Expired medications were not removed after their discard or use-by dates, and discontinued medications for two residents remained on the medication carts without active orders. Additionally, some medications, such as eye drops and insulin, were not labeled with the opened date as required, and an insulin vial and flexpen were retained beyond the 28-day discard period. Orally administered medications were stored together with externally used medications, such as suppositories and topical solutions, contrary to facility policy. During inspections, surveyors observed that oral and external medications were stored together in both medication carts and storage rooms. In one instance, a box of bisacodyl suppositories was stored with oral medications, and acetylcysteine solution was stored beside lidocaine patches. A bottle of doxycycline had an illegible expiration date, and a discontinued topical medication was not properly disposed of. The medication storage room was also found to be unsanitary, with visible dust, debris, and discarded items on the floor. Interviews with nursing staff and facility leadership confirmed that the observed deficiencies were contrary to facility policies, which require proper labeling, timely removal of expired and discontinued medications, and separate storage of oral and external medications. Staff acknowledged that the responsibility for medication storage, cleanliness, and removal of discontinued or expired medications rested with the assigned licensed nurse, and that these procedures had not been followed as required.
Failure to Follow Pureed Diet Recipe During Meal Preparation
Penalty
Summary
The facility failed to ensure that the menu and recipes were followed when preparing pureed spaghetti for residents requiring a pureed diet. During observation, a cook was seen preparing seven servings of pureed spaghetti by measuring and blending the spaghetti with hot water but did not add margarine and non-fat dry milk powder as specified in the facility's recipe. The cook confirmed during an interview that these ingredients were omitted and acknowledged that the recipe required their inclusion. Review of facility documents showed that six residents were receiving pureed food from the kitchen, and the facility's policies required food to be prepared according to recipes to conserve nutritive value and meet residents' needs. The Dietary Services Supervisor (DSS) also confirmed that the cook should have followed the recipe when preparing pureed food. The failure to follow the recipe had the potential to result in meals that did not meet the nutritional needs of residents on a pureed diet.
Improper Storage and Labeling of Resident Food Brought by Visitors
Penalty
Summary
The facility failed to implement its policy and procedure regarding the storage and labeling of food brought in by family and visitors for residents. During an inspection of the residents' refrigerator, it was observed that the refrigerator door was partially open and the unit was overfilled with food, preventing the door from closing properly. The temperature inside the refrigerator was recorded at 70 degrees Fahrenheit, which is significantly above the required maximum of 41 degrees Fahrenheit as stated in the facility's policy. Additionally, a plastic container with two tacos was found inside the refrigerator without a label indicating the current date and use by date, contrary to the facility's policy that requires all such items to be labeled and discarded after 48 hours. These observations were verified by an LVN, who acknowledged that the refrigerator should be kept closed and at the correct temperature, and that food items should be properly labeled. The ADON was also informed of and acknowledged these findings. The failure to maintain proper storage conditions and labeling for food brought in by visitors represents a deviation from the facility's established policies and procedures.
Improper Disposal of Unused Items and Accumulation of Refuse
Penalty
Summary
The facility failed to properly dispose of unused items, as required by its own policies and procedures. During an observation, a large pile of items including plastic storage drawers, a wheelchair, a laundry cart in disrepair, a soiled laundry bin, bed wires, plastic bags, metal boxes, a front wheel walker, a bedside commode, and two trash bins, all covered in dust, was found in the facility compound on the left side of the building. The Maintenance Director confirmed that most of these items were not in use and needed to be discarded, and acknowledged that their accumulation could attract rodents and pests that carry disease. A review of the facility's policies showed that garbage and trash are not permitted to accumulate and must be removed daily, and that the grounds should be kept free of litter. The Maintenance Director verified the observation and the potential for pest attraction. The Administrator was informed of these findings and acknowledged them during an interview.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, resulting in multiple documentation errors. For one resident, the electronic health record (EHR) contained another individual's PASRR Level 1 screening, which was verified by the Assistant Director of Nursing (ADON) as an upload error. Additionally, the facility's Medication Administration Records (MAR) for two residents contained inaccurate documentation regarding monitoring for side effects of apixaban, an anticoagulant. The MARs indicated changes in condition that were not supported by corresponding progress notes, and the ADON confirmed these were typographical errors made by the same licensed vocational nurse (LVN), with no actual changes in condition reported or observed. Another resident's facesheet inaccurately listed a diagnosis of unspecified schizoaffective disorder, despite no supporting documentation in the history and physical examination, no related medications prescribed, and no evidence from the acute care hospital discharge records. The MDS coordinator clarified that this diagnosis was likely entered in error by a previous staff member and was not an active diagnosis for the resident. Furthermore, a review of a different resident's Physician Orders for Life-Sustaining Treatment (POLST) indicated the presence of an advance directive, but no such document was found in the medical record. The social services director (SSD) confirmed that the resident did not have an advance directive and acknowledged the POLST should have been updated to reflect this. Finally, the discharge summary for another resident who was transferred to an acute care hospital was incomplete, as it did not specify the reason for discharge. The ADON verified that the physician had not documented the basis for the transfer, leaving the discharge summary unfinished. These documentation failures were acknowledged by facility leadership and were not in accordance with the facility's policy on nursing documentation, which requires clear, accurate, and comprehensive records to communicate patient status and care provided.
Failure to Monitor QAPI Plan of Correction for Repeated Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) committee implemented and monitored the effectiveness of its plan of correction for previously cited deficiencies at F552, F812, and F883. According to the facility's QAPI program, the committee is responsible for developing monitoring tools, creating plans of correction, and evaluating corrective actions to ensure residents receive necessary care. However, during an interview and document review, the Administrator was unable to provide documentation that the QAPI committee had monitored the effectiveness of the corrective actions for these deficiencies. Specifically, the plans of correction for F552 involved audits of informed consents and medication records, for F812 included monthly unit inspections and kitchen sanitation audits, and for F883 required maintaining a log of residents' immunization status and regular audits of immunization records. Despite these outlined actions, there was no evidence that the QAPI committee reviewed or evaluated the outcomes of these corrective measures, as required by the facility's own program.
Failure to Maintain Infection Control with Improper Storage and Labeling
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices as evidenced by multiple observations and staff interviews. During an initial tour, a box of juice and a container of creamer belonging to a resident were found placed directly on the floor at the bedside. The attending LVN confirmed that personal belongings, especially food items, should not be stored on the floor due to infection control concerns and should instead be kept in bedside drawers. The ADON also acknowledged that such storage practices do not maintain infection control standards. Additionally, shared restrooms serving multiple residents were found to contain unlabeled basins placed on top of toilet tanks. Staff members, when questioned, were unable to identify the owners of these basins and confirmed that basins in shared restrooms should be labeled for infection prevention and control. The ADON was informed of these findings and acknowledged the lapses. These observations were supported by facility document and policy reviews, confirming that the facility did not ensure proper labeling and storage of personal care items and food, thereby failing to maintain a safe and sanitary environment.
Failure to Offer and Document Annual Influenza Vaccination
Penalty
Summary
The facility failed to ensure that one of five sampled residents was offered the influenza vaccination in accordance with its own policies and procedures. The facility's policy required that all residents without medical contraindications be offered the influenza vaccine annually, with documentation of either acceptance or refusal placed in the resident's medical record. Review of the medical record for the resident in question showed that the last influenza vaccine was administered on 11/4/23, but there was no documented evidence that the vaccine was offered again in the subsequent annual period, nor was there documentation of acceptance or refusal by the resident or their representative. Interviews with the Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed that the influenza vaccine should be offered annually and that consent forms are used to ensure residents or their representatives are informed of the risks and benefits. However, all parties verified that there was no documentation in the resident's record to show that the vaccine was offered after the last administration. The resident was determined to have the capacity to make medical decisions, and the lack of documentation indicated a failure to follow the facility's established procedures for annual influenza vaccination offers.
Failure to Annually Offer and Document COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine in accordance with its own policy and procedures. The policy required that each resident be offered the COVID-19 vaccine unless medically contraindicated or already immunized, and that appropriate documentation be made if the vaccine was not administered due to contraindication, prior vaccination, or refusal. Review of the medical record for one resident revealed that after a documented declination of the COVID-19 vaccine by the resident's responsible party, there was no evidence that the vaccine or informed consent was offered again on an annual basis as required by the facility's policy. Interviews with the Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed that there was no documentation of an annual offer or consent for the COVID-19 vaccine after the initial declination. The staff acknowledged that the vaccine and consent should have been offered annually and that documentation was lacking. The resident in question had the capacity to make medical decisions, and the failure to offer and document the annual vaccine offering was verified by facility staff during the survey.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. Resident 8 experienced a delay in receiving Ciprodex Otic suspension for ear pain. Despite requesting an extension of the medication on 12/22/24, the resident did not receive it until 1/7/25, 16 days later. The licensed nurse, LVN 8, did not follow up with the physician regarding the resident's request, and there was no documentation of any follow-up calls made. The Director of Nursing (DON) acknowledged that the licensed nurses are expected to follow up with the physician for any resident's request or change in condition. Resident 13 did not receive the prescribed ceftriaxone sodium intravenous medication as ordered by the physician. The medication was scheduled to be administered on 12/12/24 at 2100 hours, but there was missing documentation in the Medication Administration Record (MAR) to confirm its administration. RN 1 verified the missing documentation and stated that all medication administration must be documented in the MAR. Further investigation revealed that the ceftriaxone medication was not delivered by the pharmacy, and there was no record of it being removed from the facility's emergency kit. The DON confirmed the missing documentation and stated that the medication was not administered since it was not documented. The DON emphasized that RNs must document in the MAR after administering any IV medications. These failures in medication administration and documentation had the potential to negatively affect the residents' health condition and well-being.
Failure to Administer Correct Probiotic as Ordered
Penalty
Summary
The facility failed to provide the appropriate pharmaceutical services for one of the residents, identified as Resident 8, by not administering the medication as ordered. The facility's policy and procedure (P&P) for medication orders require specific details such as the name, strength, dose, and route of administration. However, Resident 8, who was capable of understanding and making decisions, reported receiving a different probiotic than what was prescribed. The prescribed probiotic was saccharomyces boulardii, but the resident was given acidophilus instead, which led to changes in her bowel movements. Interviews with LVN 3 and LVN 8 confirmed that the resident was administered acidophilus because it was the facility's current supply, despite the order for saccharomyces boulardii. Both LVNs acknowledged the discrepancy between the prescribed and administered probiotics. The Director of Nursing (DON) stated that the nurses should have contacted the physician to clarify and adjust the order to match the available supply, acknowledging the findings of the surveyors.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in the management of respiratory equipment. Resident 3's oxygen tubing was not changed weekly as required, and the CPAP mask was improperly stored, with part of it hanging out of an open bag. This was confirmed by an LVN who verified the tubing was dated 11/24/24, indicating it had not been changed weekly as ordered. Resident 3 used the CPAP at night, and the staff was responsible for storing the equipment. Resident 4's suction equipment was not maintained according to the facility's policy and procedure. The Yankauer tip suction was found with thick brownish dried secretion and was stored in a bag dated 9/21/24, indicating it had not been cleaned or changed as necessary. The suction canister also had brownish dried residue. An IP verified these findings and acknowledged the need for equipment change. Resident 5's oxygen tubing was not stored properly, as it was found hanging over the side rails and not changed weekly as ordered. An LVN confirmed the nasal cannula was exposed and improperly stored, with the bag dated 12/1/24, indicating non-compliance with the weekly change order.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer medications safely. Resident 6 was found with a bottle of sealed Motrin 200 mg, a plastic medication cup containing one tablet of Oscal 500/200 with vitamin D, and two capsules of Docu Soft 100 mg inside the drawer of their bedside table. The resident had not been assessed for self-administration of medications, which is a requirement according to the facility's policy. The policy states that residents can self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team, and this decision must be documented in their medical records and care plans. During an observation and interview, Resident 6 indicated that they placed the medications in the drawer after the licensed nurse left the room, as they did not want to take all the medications at once. The DSD confirmed the presence of the medications and acknowledged that Resident 6 needed to be assessed for self-administration and required a physician's order for the Motrin. Additionally, LVN 3 admitted to not staying with Resident 6 until all medications were taken and confirmed there were no physician's orders, self-administration assessment, or care plan for Resident 6 to self-administer medications.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect Resident 2 from physical abuse by another resident, Resident 1. Resident 1, who had severe cognitive impairment and was unable to make decisions, exhibited aggressive behavior by hitting Resident 2 on the left shoulder and face. This incident occurred after Resident 1 had previously shown signs of aggression, such as pushing a nurse and pulling another staff member's hair, without provocation. Despite these behaviors, the facility did not implement a care plan to address Resident 1's aggression or notify the physician for further intervention. The facility's policies on abuse prohibition and behavior management were not effectively followed. The staff failed to identify and correct the situation where abuse was likely to occur, as Resident 1's aggressive behavior was not adequately managed. The interdisciplinary team did not evaluate Resident 1's behavior comprehensively, and no interventions were put in place to ensure the safety of other residents, including Resident 2. Interviews with staff revealed a lack of communication and awareness regarding Resident 1's aggressive behavior. CNA 1 and LVN 2 were not fully informed about Resident 1's actions, and RN 1 admitted to not initiating a care plan for Resident 1's behavior change. The Director of Nursing and the Administrator acknowledged that the physician should have been notified to manage Resident 1's behavior, but this step was not taken, leading to the incident with Resident 2.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as Resident 2, during meal assistance. On August 7, 2024, at 0835 hours, a Certified Nursing Assistant (CNA 1) was observed standing over Resident 2 while feeding her as she lay in bed. This action was confirmed during an interview with CNA 1 at 0840 hours, where she acknowledged standing over the resident during the feeding process. The incident highlights a deficiency in promoting a dignified existence and respect for the resident's rights, as the manner of feeding did not align with treating the resident with respect.
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 6,743 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Healthcare Center Of Orange County | 0.5 mi | ★★★★★ | 8 | 0 |
| Anaheim Crest Nursing Center | 0.7 mi | ★★★★★ | 30 | 0 |
| West Anaheim Medical Center D/p Snf | 0.7 mi | ★★★★★ | 16 | 0 |
| Buena Park Nursing Center | 0.8 mi | ★★★★★ | 47 | 0 |
| Park Anaheim Healthcare Center | 0.9 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.