Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Hills Nursing Center during CMS and state inspections, most recent first.
The facility failed to complete a PASRR Level II evaluation for a resident who screened positive for SMI on the Level I and had diagnoses of depression and unspecified psychosis. The state PASRR authority documented that staff were unresponsive to repeated attempts to schedule the evaluation, closed the case, and the LN and DON both confirmed the Level II evaluation was never completed.
Failure to Care Plan for IV Access Site: A resident with CHF had an IV access site that was observed with a dressing dated weeks earlier, blood in the tubing, slight redness, and peeling edges. The resident said the dressing had not been changed and the IV was not being used for meds. The LPN could not find an IV care plan, and the DON stated one should have been developed to monitor the site for infection and other complications.
Failure to monitor and assess an IV access site for a resident with CHF and anticoagulant use. The resident said the dressing had not been changed since 1/29/26, and the site was observed with a dated dressing, blood in the catheter tubing, slight redness, and peeling edges. An LPN stated the site should be checked each shift and the dressing changed weekly, while another nurse said there was no written order for IV monitoring and flushing and no MAR documentation of shift checks. The DON stated staff should have followed IV site monitoring procedures.
A facility failed to complete an annual performance evaluation to verify competency for one CNA. Review of the personnel file showed the most recent evaluation was dated years earlier, and the DON stated staff should be evaluated annually to ensure they have the necessary skills to provide quality care and maintain compliance. The facility policy stated each employee's job performance shall be reviewed and evaluated at least annually.
Wet Food Service Items Stacked Before Air Drying: A dietary aide stacked food lids and meal delivery trays while they were still wet after the dishwasher cycle. The MDS stated items are expected to air dry before being put away or stacked for the tray line, and that moisture build-up on utensils, trays, food plates, and covers could lead to food borne illness risk for residents.
Infection control practices were not followed for three residents. A resident on C. diff precautions had stool-soiled linens left in an open trash can and an unsecured bag on the bathroom floor, a resident with a urinary catheter had the drainage bag hanging above the bladder level, and a resident with Covid-19 had a trash bag of used tissues placed next to the meal tray on the bedside table. Staff and the IP acknowledged the improper linen handling and catheter placement, and the DON stated the trash bag should not have been beside the meal tray.
A resident with a history of Major Depressive Disorder and documented aggressive and elopement behaviors was not referred to psychiatry, despite multiple incidents and staff observations. Facility staff did not communicate or document these behaviors according to policy, and the care plan did not reflect the resident's behavioral issues.
A resident with hemiplegia and high fall risk experienced a fall resulting in a traumatic hematoma due to a CNA providing care alone, contrary to the care plan requiring two-person assistance. The facility's policy on ADLs was not followed, as confirmed by staff interviews and record reviews.
A resident with osteoporosis experienced a decline in range of motion in his hands, affecting his ability to perform daily activities. Despite observations and interviews indicating the resident's limitations, the facility failed to implement a care plan or provide necessary rehabilitation services. Staff members did not report the resident's condition changes, and quarterly rehab screens were not conducted, leading to a lack of appropriate interventions.
The facility failed to provide palatable and properly prepared meals, leading to resident dissatisfaction. Observations revealed issues with food temperature, taste, and presentation, with residents frequently receiving cold and unappealing meals. The Dietary Supervisor and Registered Dietician acknowledged these issues, noting the absence of a formal process for tracking test trays and the need for improved meal presentation. The facility's policy required poorly prepared food to be improved or replaced, but this was not consistently followed.
A resident with a history of heart failure and minimal cognitive deficits was served meals that did not align with their preferences, such as spicy food and gravy, despite these dislikes being documented. The Dietary Supervisor and Registered Dietician acknowledged the oversight, which could lead to poor meal intake and weight loss. The facility lacked a policy for menus, contributing to the deficiency.
The facility failed to maintain food safety and sanitation standards in dietary services. Observations included cereal containers on the floor, a dented can of tomato paste, and food boxes stacked too close to fire sprinklers. Additionally, food seasonings lacked opened dates, a dishwashing machine lacked a proper air gap, and a sanitation bucket was improperly placed on a food preparation table, all contrary to facility policies.
A facility failed to follow the care plan for a diabetic resident, leading to hospitalization. The resident, with a history of gangrene, was not wearing shoes as required by the care plan, resulting in foot abrasions and swelling. The omission of this intervention from the revised care plan contributed to the deficiency.
The facility failed to create and implement specific care plans for two residents, one with limited range of motion and another with PTSD. A resident with osteoporosis showed a decline in hand mobility, requiring assistance with meals, but lacked a care plan addressing this issue. Another resident with PTSD had no care plan for managing triggers, risking retraumatization. Staff acknowledged these needs, but failed to document or address them adequately, contrary to facility policies on trauma-informed care.
A resident with protein-calorie malnutrition experienced an unplanned weight loss of 18.3 pounds in one month, but the facility failed to update the resident's nutritional care plan. The RD acknowledged the oversight, and the DON expected the care plan to be updated, as per facility policy.
A resident's pain medication order was not properly clarified, lacking specific parameters and frequency, which could lead to overmedication. Staff interviews confirmed the order was incomplete and should have been clarified with the physician. The facility's policy did not provide guidance on this issue.
A facility failed to provide trauma-informed care to a resident with PTSD, as staff were unaware of the resident's diagnosis and triggers. The resident, a military veteran, identified wartime battle-related events as a trigger. The Director of Nursing emphasized the importance of staff awareness to prevent psychological distress, highlighting a deficiency in the facility's implementation of its trauma-informed care policy.
A facility failed to reconcile controlled medications with the MAR for a resident, leading to a potential risk of drug diversion. The resident had an order for Norco, but the MAR was blank for a dose signed out in the Controlled Drug Record. Interviews with staff confirmed the missing documentation, and the DON acknowledged the discrepancy, highlighting a failure to adhere to the facility's policy on controlled substances.
A resident prescribed Trazodone for depression with sleep disturbances was inaccurately monitored, with records showing disturbances during day and evening shifts, contrary to staff reports of nighttime disturbances. This discrepancy risked unnecessary medication due to inaccurate data used for medication evaluation.
The facility failed to properly dispose of garbage and refuse, as observed when a Dietary Aide transported a lidless trash barrel to the garbage area. One dumpster had an unsecured lid, and another was overflowing, preventing proper closure. The Dietary Supervisor confirmed the importance of securing dumpsters to prevent pest attraction, as per facility policy and FDA guidelines.
A resident with protein-calorie malnutrition and type 2 diabetes experienced significant weight loss, which was not documented in a timely manner in the EHR. The IDT note was entered late, and an SBAR Communication Form was not completed, delaying communication of the resident's condition to healthcare providers. Staff interviews confirmed the documentation should have been done promptly, as per facility policy.
The facility failed to ensure that three residents fully understood the arbitration agreements they signed. One resident with severe cognitive deficits signed without capacity, another had a family member sign without being the responsible party, and a third resident did not receive a copy to review. The facility lacked documentation and a policy for arbitration agreements.
The QAA Committee failed to address food complaints raised by residents and noted by surveyors, focusing instead on other issues like falls and diabetic care. The DON admitted that food-related concerns from resident council meetings were not discussed in QAPI meetings, leading to unresolved issues affecting residents' quality of life.
The facility failed to follow infection control procedures when a CNA did not wear PPE while assisting a resident on EBP, and an LN did not perform hand hygiene consistently after glove removal. The LN also wore bandages that could harbor bacteria, contrary to facility policy.
A facility failed to complete an Admission Comprehensive Assessment for a resident within the required 14 days due to the departure of the MDS Nurse and a delay in hiring a replacement. The resident, admitted with falls and fractures, was not fully assessed, and CMS was not informed of their health status. Interviews revealed a lack of awareness and assumptions about the completion of assessments by the ADON, DON, and Administrator.
A resident did not receive a prescribed blood thinner for 12 days due to the facility's failure to clarify a physician's order. The process involved documenting the order in a Transportation Log and discussing it at a Stand Up meeting, but the note was not properly followed up. Interviews revealed a lack of documentation and discussion, leading to a delay in medication administration.
A resident with limited English proficiency did not receive adequate communication support in their native Arabic dialect, as the facility failed to implement its language access policy. Staff used hand gestures and Google Translate instead of trained interpreters or telephone services, and relied on a family member for translation. Interviews revealed a lack of staff training and awareness about available translation services.
The facility failed to implement their infection control program when two CNAs did not wear proper full PPE while providing care to COVID-positive residents, and one CNA improperly discarded a used N95 mask. Both CNAs admitted to not wearing face shields or goggles, and a Licensed Nurse confirmed the expectation for proper PPE use and disposal.
Failure to Complete PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure completion of the PASRR Level II evaluation for 1 of 2 residents reviewed for PASRR. Resident 3 was admitted to the facility and later readmitted after a hospitalization with diagnoses of depression and unspecified psychosis. The resident's PASRR Level I, dated 11/18/25, indicated a positive screen for serious mental illness and that a Level II evaluation was required. A state PASRR authority correspondence letter dated 11/20/25 stated that a Level II mental health evaluation could not be completed because facility staff were unresponsive to two or more separate attempts at communication within 48 hours of the Level I screening, and the case was closed. During interviews, LN 12 acknowledged receiving the correspondence, confirmed the facility did not respond, and stated the Level II evaluation had not been completed. The DON also acknowledged the facility received the correspondence, did not follow up after the case was closed, and confirmed that no Level II evaluation had been completed for Resident 3.
Failure to Care Plan for IV Access Site
Penalty
Summary
Facility failed to develop a care plan related to the care of the IV access site for Resident 32, who was admitted with diagnoses including chronic systolic congestive heart failure. On 02/10/26, Resident 32 was observed resting in bed with family members present and expressed concern that the dressing on the IV access site had not been changed since 1/29/26. During the observation, the resident stated the staff were not using the IV access site for medications. The IV access site dressing was dated 1/29/26. At the time of the observation, blood was noted in the catheter tubing, the access site appeared slightly reddened, and the adhesive dressing was peeling off from the edges. A review of the physician's order recap report showed an order for IV hydration of sodium chloride solution for dehydration that was completed on 1/30/26. During record review, the Licensed Nurse could not find a care plan for the IV access site and stated that a care plan should have been developed for assessing and monitoring the IV access site. The DON also stated that a care plan should have been developed to monitor the IV access site for infections and other complications. The facility's care plan documentation stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Failure to Monitor and Assess IV Access Site
Penalty
Summary
The facility failed to monitor and assess the IV access site for Resident 32, who was admitted with diagnoses including chronic systolic congestive heart failure and long-term use of anticoagulant therapy. During an observation in the resident’s room, Resident 32 stated that the IV dressing had not been changed since 1/29/26 and said staff were not using the IV access site for medications. The IV site dressing was observed to be dated 1/29/26, with blood noted in the catheter tubing, slight redness at the access site, and the adhesive dressing peeling off at the edges. Record review showed Resident 32 had an order for IV hydration with sodium chloride for dehydration, which was completed on 1/30/26. A nurse stated the IV access site should be checked every shift for signs of infection and flushed with normal saline to keep it open, and that the dressing should be changed weekly. Another nurse stated there was no written order in the record for IV monitoring and flushing and that the MAR did not document staff monitoring and flushing the IV access site each shift. The DON stated staff should have followed procedures in monitoring and assessing IV access sites to prevent complications and infections. The facility’s policy on peripheral and midline IV dressing changes stated the purpose was to prevent complications associated with IV therapy, including catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings.
Failure to Complete Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to complete an annual performance evaluation to verify competency for one of five certified nursing assistants (CNA 1). During a concurrent review of personnel files and interview with the Director of Staff Development and Assistant Director of Staff Development, CNA 1 was identified as having been hired on 7/30/13, and the most recent performance evaluation in the personnel file was dated 4/16/20. In a later interview, the Administrator and Director of Nursing stated that staff should undergo performance evaluations annually to ensure they have the necessary skills to provide quality care and maintain compliance. The facility's policy titled, Performance Evaluations, dated 9/20, stated that the job performance of each employee shall be reviewed and evaluated at least annually.
Wet Food Service Items Stacked Before Air Drying
Penalty
Summary
The facility failed to follow its drying procedure when dietary food service trays and food covers were stacked while still wet instead of being allowed to completely air dry. During an observation of the dishwasher sanitization process on 02/10/2026 at 10:15 A.M., Dietary Aide 5 stacked together a rack of food lids and a rack of meal delivery trays that were still wet. During an interview at 10:25 A.M., Dietary Aide 5 stated that plates, trays, and covers are left to air dry for a few minutes after coming out of the dishwasher and that there should not be any moisture between items because moisture can make napkins and diet cards wet and illegible. At 10:45 A.M., the Manager for Dietary Services stated that all items are expected to be air dried before being put away or stacked for the tray line, and that moisture build-up on utensils, trays, food plates, and covers could lead to food borne illness risk for residents. The facility policy, Food Preparation and Service, stated that all food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations, and the California Health and Safety Code requires equipment and utensils to be air dried after cleaning and sanitizing before contact with food.
Infection Control Practices Not Followed for Soiled Linens, Catheter Drainage, and Trash Placement
Penalty
Summary
The facility failed to implement infection prevention and control practices for three sampled residents. One resident was admitted with enterocolitis due to C. diff and was on contact precautions. During an observation, a strong odor of stool was noted in the room bathroom, where multiple towels visibly soiled with yellow stool overflowed from a small open trash can. A large clear plastic bag containing soiled sheets and towels was sitting on the bathroom floor in front of the sink, the bag was untied and unsecured, and no covered laundry hamper was present in the room. CNA 11 and the IP both acknowledged the soiled linens and stated they should not have been left in an open container or unsecured bag on the floor. A second resident was admitted with a urinary tract infection. During an observation, the resident’s catheter drainage bag was hanging from the upper left side rail of the bed above the level of the bladder, and the tubing contained brown, cloudy urine. The resident stated it burned and felt irritated at the catheter insertion site. CNA 12, LN 11, and the IP all reviewed the photograph of the drainage bag placement and stated the bag should be positioned below the level of the bladder; they stated that positioning it above the bladder could allow urine to flow back toward the bladder and increase the risk of infection. A third resident was admitted with diagnoses that included Covid-19. During meal service, a blue trash bag filled with dirty and used crumpled tissue paper was observed next to the resident’s meal tray on the bedside table. The resident stated the meal tray should not be placed next to trash. The DON stated the trash bag should not have been on the bedside table next to the meal tray and that staff were expected to follow infection control practices to help prevent the spread of infection.
Failure to Refer Resident with Behavioral Issues for Psychiatric Evaluation
Penalty
Summary
The facility failed to ensure proper communication and referral for behavioral health services for a resident with a history of Major Depressive Disorder and documented behavioral manifestations. Despite multiple documented incidents of the resident attempting to elope and displaying aggressive behaviors towards staff and other residents, there was no evidence that these behaviors were communicated to the appropriate staff or that a referral to psychiatry was made, as required by facility policy. The resident's care plan did not reflect these behavioral issues, and social services notes lacked documentation of referrals or communication with the charge nurse regarding the incidents. Interviews with facility staff, including the Social Services Director and Assistant Director of Nursing, confirmed that the process for referring residents with behavioral issues to psychiatric evaluation was not followed. The Social Services Director was unaware of the resident's behaviors in February and acknowledged the absence of a paper trail or intervention following the early identification of behavioral issues. The facility's policy required close monitoring, assessment, and interdisciplinary communication for residents exhibiting behavioral difficulties, but these steps were not documented or implemented for this resident.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to Resident 1's care plan, which required two-person assistance during care activities. Despite this requirement, a certified nurse assistant (CNA) provided care alone, leading to a witnessed fall. Resident 1, who was admitted with conditions including hemiplegia, hemiparesis, and dysphagia following a stroke, was at high risk for falls as indicated by multiple evaluations. On the night of the incident, while the CNA was turning Resident 1 to the left side during care, the resident rolled out of bed, resulting in a traumatic hematoma on the forehead. Interviews and record reviews confirmed that Resident 1 was dependent on assistance for most activities of daily living (ADLs) and required two-person assistance for bed mobility, transfer, and toileting hygiene. The Director of Nursing (DON) and other staff members acknowledged that the care plan was not followed, as the CNA did not seek additional help. The facility's policy on ADLs emphasized providing care to maintain or improve residents' abilities, which was not adhered to in this case.
Failure to Address Decline in Resident's Range of Motion
Penalty
Summary
The facility failed to identify and address a decline in range of motion (ROM) for a resident, referred to as Resident 27, who was admitted with a diagnosis of osteoporosis. During an initial tour, it was observed that Resident 27 had difficulty fully extending and straightening his fingers, which affected his ability to perform daily activities such as cutting food and using utensils. Despite these limitations, there was no care plan in place to address the resident's hand condition, and no orders for rehabilitation or restorative nursing assistance were found in his records. Interviews with various staff members, including certified nurse assistants (CNAs) and licensed nurses (LNs), revealed that the resident's condition had not been reported or addressed appropriately. CNA 1, who had known the resident for a long time, acknowledged the resident's difficulty in opening his hands and the need for assistance during meals. However, the change in the resident's condition was not reported to a licensed nurse, as confirmed by interviews with other CNAs and LNs. The Director of Rehabilitation and the Minimum Data Set Nurse (MDSN) were also unaware of the resident's hand limitations, and quarterly rehab screens for the resident were not found. The occupational therapy evaluation conducted on 11/1/24 confirmed that Resident 27's hand joints were fixed in a flexed position, causing pain during passive ROM and preventing active ROM. The evaluation indicated that the resident's functional abilities were limited due to contractures, and the therapy would focus on preventing further flexion. The facility's policy on resident mobility and ROM, dated July 2017, stated that residents should not experience an avoidable reduction in ROM and should receive treatment to prevent further decrease, which was not adhered to in this case.
Deficiency in Food Quality and Presentation
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, flavorful, and maintained its nutritional value, as observed during multiple dining observations. Residents consistently reported dissatisfaction with the taste, temperature, and presentation of the food. Complaints included cold food, lack of flavor, and unappealing presentation. Some residents reported receiving the same meals repeatedly, such as scrambled eggs for breakfast, and others noted that the food was sometimes too spicy or salty, contrary to their preferences. These issues were documented during dining observations and resident council meetings over several months. During interviews, both the Dietary Supervisor (DS) and Registered Dietician (RD) acknowledged the issues with food quality and presentation. The DS admitted that there was no formal process to track test trays and that the pureed meals needed to be more appealing. The RD mentioned that while they follow recipes, there is room for improvement in taste and presentation without altering the menus significantly. Both the DS and RD recognized that the late delivery of meals could affect food quality and residents' appetites, potentially leading to decreased meal intake and weight loss. The facility's policy on food storage and preparation indicated that poorly prepared food should not be served and should be improved or replaced. However, the facility did not provide a specific policy for test trays or meal rounds. The lack of adherence to these policies and procedures contributed to the deficiency, as evidenced by the repeated resident complaints and observations of unappetizing and improperly prepared meals.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident's preferences, leading to a potential risk of poor meal intake and weight loss. The resident, who had a history of heart failure and minimal cognitive deficits, was observed receiving meals that did not align with their stated preferences. On two separate occasions, the resident was served food that was either spicy or included gravy, both of which were against their documented dislikes. The menu ticket for the resident did not indicate the need for chopped meats, yet the resident received chopped chicken, and their dislike for gravy was not honored. Interviews with the Dietary Supervisor and Registered Dietician revealed that the resident's preferences were not followed, which could lead to the resident becoming upset and potentially losing weight due to poor meal intake. The facility did not provide a policy and procedure for menus, indicating a lack of structured guidance in ensuring resident preferences are consistently met. This oversight in accommodating the resident's dietary preferences was identified through observations, interviews, and record reviews.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in dietary services, as observed during a kitchen tour. Two individual-sized cereal containers were found on the floor of the dry pantry storage, contrary to the facility's policy that requires food to be stored at least six inches off the floor to prevent contamination and pest infestation. Additionally, a large dented can of tomato paste was stored with other canned goods, posing a risk of botulism, which is against the facility's policy that prohibits the use of dented cans. Further observations revealed that multiple brown boxes containing food were stacked above the red line in the dry storage food pantry, which is a fire hazard as it interferes with the fire sprinkler's efficiency. The facility's policy and the California Building Code require that storage be maintained at least 18 inches below sprinkler head deflectors. Moreover, five food seasonings were found without an opened date, which is against the facility's policy that requires labeling and dating to ensure the efficiency and taste of the seasonings over time. The facility also failed to ensure proper plumbing and sanitation practices. The low-temperature dishwashing machine lacked a proper air gap system, which is necessary to prevent backflow of contaminated fluids, as per the facility's policy and the Federal FDA Food Code. Additionally, a red sanitation bucket was placed on a food production table, risking cross-contamination with food, which violates the facility's policy against using cleaning products in food preparation areas.
Failure to Implement Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate interventions according to the comprehensive care plan for a resident with diabetes, leading to a deficiency. Resident 42, who had a history of diabetes and gangrene on the left second toe, was admitted to the facility with severe cognitive deficits. Despite the care plan indicating the need for diabetic shoes on both lower extremities, this intervention was omitted in the revised care plan initiated on 10/26/24. As a result, the resident was found with abrasions on the left great toe and left third toe, and was not wearing shoes while in a wheelchair, which was against the care plan's requirements. The lack of adherence to the care plan led to Resident 42 being hospitalized due to swelling in the left foot, potentially exacerbated by the abrasions. The Director of Nursing acknowledged that the plan of care required the resident to wear shoes to provide foot protection and prevent complications. The facility's policy on foot care, which emphasizes preventing complications from medical conditions, was not followed, as there was no documentation indicating that the diabetic shoes were monitored or applied.
Failure to Implement Resident-Specific Care Plans
Penalty
Summary
The facility failed to develop and implement resident-specific care plans for two residents, leading to deficiencies in addressing their medical needs. Resident 27, who was admitted with osteoporosis, exhibited a decline in the range of motion in his hands, which was not addressed in his care plan. Despite observations and interviews indicating that Resident 27 had difficulty using his hands, requiring assistance with meals, and showing signs of hand contractures, there was no care plan in place to manage or mitigate these issues. The facility's staff, including CNAs and a licensed nurse, acknowledged the resident's condition but failed to report or document it adequately, resulting in a lack of appropriate interventions. Similarly, Resident 294, diagnosed with PTSD, did not have a care plan that addressed his specific triggers, which could potentially retraumatize him. The Social Services Director and the Director of Nursing both recognized the importance of identifying and managing PTSD triggers to prevent psychological distress, yet the care plan lacked these critical interventions. The facility's policies emphasized the need for trauma-informed care and individualized care plans, but these were not effectively implemented for Resident 294, leaving him vulnerable to distressing situations.
Failure to Update Nutritional Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was revised and updated for a resident reviewed for nutrition. The resident, who was admitted with a diagnosis of protein-calorie malnutrition, experienced a significant, unplanned weight loss of 18.3 pounds in one month. Despite this, the resident's nutritional care plan was not updated to reflect the recent weight loss, as acknowledged by the Registered Dietitian during an interview. The Director of Nursing stated that it was her expectation for the care plan to be updated, especially given the resident's risk for weight loss. The facility's policy on weight assessment and intervention, as well as comprehensive person-centered care plans, requires that care plans address identified causes of weight loss and be revised as the resident's condition changes. However, a review of the resident's care plan indicated no revisions or interventions related to the weight loss.
Failure to Clarify Pain Medication Order
Penalty
Summary
The facility failed to ensure that a resident's pain medication order was properly clarified to include necessary parameters and frequency of administration. Resident 86, who was admitted with a diagnosis including post laminectomy, had an order for Norco Oral Tablet 5-325 mg to be given twice daily as needed for pain management. However, the order lacked specific instructions regarding the frequency and pain level parameters, which are essential for safe administration. This oversight was identified during a review of the resident's Medication Administration Record (MAR). Interviews with facility staff, including the Infection Preventionist (IP), a Licensed Nurse (LN 2), and the Director of Nursing (DON), revealed a consensus that the pain medication order was incomplete and should have been clarified with the prescribing physician. The staff acknowledged that the absence of specific parameters could lead to the risk of the resident being overmedicated. The facility's policy on pain management did not provide guidance on clarifying such orders, contributing to the deficiency.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to Resident 294, who was diagnosed with PTSD, depression, and alcohol use. The resident, a military veteran who had been stationed in Iraq, identified wartime battle-related events as a trigger for his PTSD. Despite this, interviews with CNAs 21 and 22 revealed that they were unaware of Resident 294's PTSD diagnosis and his specific triggers. This lack of awareness among the staff could potentially lead to re-traumatization of the resident. The Director of Nursing acknowledged the importance of staff being informed about Resident 294's PTSD diagnosis to avoid causing psychological distress. The facility's policy on Trauma-Informed and Culturally Competent Care, revised in August 2022, emphasizes the need to minimize triggers and re-traumatization for trauma survivors. However, the failure to communicate Resident 294's PTSD diagnosis and triggers to the staff indicates a deficiency in implementing this policy effectively.
Controlled Medication Reconciliation Failure
Penalty
Summary
The facility failed to ensure that controlled medications were properly reconciled with the Medication Administration Record (MAR) for one resident, leading to a potential risk of drug diversion. Resident 86, who was admitted to the facility, had an order for Norco Oral Tablet 5-325 mg to be administered twice daily for pain management. The order was initially set to be discontinued on 10/23/2024 and then restarted with a new order on 10/24/2024. However, the MAR indicated that the only medication given on 10/24/2024 was at 8:27 P.M., despite a dose being signed out at 9:00 A.M. on the Controlled Drug Record. During interviews, Licensed Nurse 2 (LN 2) confirmed that the MAR was blank for the 9:00 A.M. dose on 10/24/2024, and there was no documentation to verify that the medication was given to Resident 86. The Director of Nursing (DON) acknowledged the missing dose and emphasized that all doses must be accounted for and justified in the records. The facility's policy on controlled substances requires nursing staff to count controlled medication inventory at the end of each shift and reconcile any discrepancies, which was not adhered to in this instance.
Inaccurate Monitoring of Psychotropic Medication Use
Penalty
Summary
The facility failed to accurately monitor a resident who was prescribed Trazodone HCL for Major Depressive Disorder with sleep disturbances. The monitoring records inaccurately documented the resident as having sleep disturbances during the day and evening shifts, while no disturbances were recorded during the night shift. However, interviews with staff and the resident's roommate indicated that the resident was actually awake and active during the day and experienced sleep disturbances at night. This discrepancy in monitoring led to the potential risk of the resident receiving unnecessary psychotropic medication due to inaccurate data being used for medication evaluation and potential gradual dose reductions. The resident, who was admitted with a diagnosis of dementia and depression, was on behavioral monitoring for sleep disturbances related to the use of Trazodone. Interviews with CNAs and LNs revealed that the monitoring records were not reflective of the resident's actual sleep patterns, as the resident was reported to be awake at night and not during the day. The inaccurate monitoring records could mislead physicians and pharmacists in evaluating the effectiveness of the medication and determining the need for dose adjustments, thereby putting the resident at risk of unnecessary medication administration.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that outdoor garbage and refuse were properly disposed of, leading to a potential unsafe environment. During an observation and interview with the Dietary Supervisor, it was noted that a Dietary Aide was transporting a kitchen trash barrel without a lid to the facility's garbage area. The facility had three dumpsters located outside the kitchen by the parking lot. The first dumpster was observed with one of its two lids not securely closed, and the third dumpster was overflowing with trash bags, preventing the lids from being fully closed and secured. The Dietary Supervisor acknowledged that the kitchen trash barrel should have had a lid while being transported and that the dumpsters should not be overflowing, as this prevents them from being securely closed. The facility's policy on garbage and refuse disposal, dated November 2017, requires that garbage and refuse containers be maintained in good condition and that waste be properly contained with lids covered. The 2022 FDA Food Code also mandates that outside receptacles for refuse and recyclables have tight-fitting lids. The failure to adhere to these guidelines could attract pests and pose a problem for the facility.
Failure to Timely Document Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident's significant weight loss was properly documented in a timely manner in the electronic health record (EHR). Resident 15, who was admitted with diagnoses including protein-calorie malnutrition and type 2 diabetes, experienced an unplanned weight loss of 18.3 pounds in one month. The Interdisciplinary (IDT) Note regarding this weight loss was entered as a late entry on 10/29/24, despite the effective date being 10/4/24. This delay in documentation meant that the resident's condition was not communicated promptly to all healthcare providers, potentially impacting the resident's care. Interviews with facility staff, including the Registered Dietitian (RD), Assistant Director of Nursing (ADON), and Director of Nursing (DON), revealed that the IDT note should have been entered immediately following the IDT meeting. The ADON also noted that an SBAR Communication Form should have been completed due to the change in the resident's condition. The facility's policy on changes in a resident's condition or status, dated February 2021, requires timely documentation of such changes. The failure to document promptly was acknowledged by the staff, highlighting a lapse in following the facility's documentation policy.
Failure to Ensure Residents' Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that three residents fully understood the arbitration agreement they entered into. Resident 68, who had severe cognitive deficits due to dementia, signed an arbitration agreement despite lacking the capacity to understand or make decisions. The Admission Coordinator and Admissions Director acknowledged that the resident's conservator should have been notified, but there was no documentation to support that this occurred. The Director of Nursing confirmed that the resident's cognitive impairments were evident from the initial assessment, and the facility did not provide a policy and procedure for arbitration agreements. Resident 72's arbitration agreement was signed by a family member who was not the responsible party or legal representative. The resident, who had minimal cognitive deficits, stated that the agreement was never explained to him, and he was not given a copy to review. The Admissions Coordinator and Admissions Director confirmed that there was no documented evidence that the agreement was explained or that a copy was provided to the resident. Resident 34, who had no cognitive deficits, signed an arbitration agreement without fully understanding its implications. The resident was not given a copy of the agreement to review, which would have allowed her to cancel it within 30 days if desired. The Admissions Coordinator and Admissions Director confirmed the lack of documentation regarding the explanation of the agreement or the provision of a duplicate copy. The facility did not provide a policy and procedure for arbitration agreements.
QAA Committee Fails to Address Food Complaints
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to identify and address quality deficiencies related to food complaints raised by residents during council meetings and noted by surveyors during a recertification survey. The Director of Nurses (DON) acknowledged that while the QAPI meetings focused on issues such as falls, diabetic care, inaccurate hospital orders, unsafe discharges, and weight loss, they did not address the food-related concerns reported in resident council meetings from May to September 2024. The facility's policy and procedure for Quality Assessment & Assurance mandates the committee to coordinate and evaluate activities under the QAPI program, including developing and implementing plans of action to correct identified quality deficiencies. However, the food issues were not brought up in the QAPI meetings, resulting in unresolved issues affecting the residents' quality of life.
Infection Control Lapses in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control procedures in two observed instances. In the first instance, a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) while assisting a resident on Enhanced Barrier Precautions (EBP) with a transfer. The CNA acknowledged the oversight and recognized the potential risk of spreading infections. The Infection Preventionist and Director of Nursing confirmed that staff had been trained on EBP requirements, and the facility's policy clearly outlined the need for gowns and gloves during high-contact activities. In the second instance, a Licensed Nurse (LN) did not consistently perform hand hygiene after removing gloves while preparing medications for a resident on EBP. The LN had adhesive bandages on her hands, which were not removed, potentially harboring bacteria. The Infection Preventionist and Director of Nursing emphasized the importance of hand hygiene and the inappropriateness of using bandages that could become wet and carry infections. The facility's hand hygiene policy required hand washing immediately after glove removal, which was not followed in this case.
Failure to Complete Admission Comprehensive Assessment
Penalty
Summary
The facility failed to complete an Admission Comprehensive Assessment for a resident according to the Minimum Data Set (MDS), a requirement by CMS. The resident was admitted with diagnoses including falls and fractures of the left femur. Upon review, it was found that the comprehensive assessment was still in progress and had not been completed within the mandated 14 days after admission. This oversight was attributed to the departure of the facility's Minimum Data Set Nurse (MDSN), who left on November 20, 2024, and the subsequent delay in hiring a replacement. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator (ADM) revealed a lack of awareness and assumption that the assessments were completed. The ADON acknowledged the overdue status of the assessment and the potential impact on CMS's awareness of the resident's health status. The DON was unaware of the incomplete assessment, and the ADM assumed all assessments were completed after the MDSN's departure. This failure resulted in the resident not being fully assessed for potential health issues and CMS not being informed of the resident's current health status.
Failure to Clarify Physician's Order for Blood Thinner
Penalty
Summary
The facility failed to clarify a physician's order for a blood thinner medication for a resident, resulting in the resident not receiving the medication for 12 days. The resident was admitted with a diagnosis of atherosclerosis of the coronary artery bypass graft. The Director of Nursing (DON) explained that the process for handling new prescriptions involved documenting the order in a Transportation Log book and discussing it at the next Stand Up meeting. However, a note regarding the need to follow up with a neurologist about the blood thinner was written in the log but not signed or timed, and no progress note was found indicating any discussion with the neurologist. Interviews with the DON and Licensed Nurses (LNs) revealed that the note should have been discussed during a Stand Up meeting, but there was no record of such a discussion. The charge nurse, who was responsible for following up on the medication order, did not recall discussing the blood thinner during the meeting. As a result, the resident did not receive the medication until 12 days after the initial note was written, potentially putting the resident at risk for complications. The facility was unable to provide a policy regarding the process for following physician's orders for medications.
Failure to Provide Adequate Language Services for Resident
Penalty
Summary
The facility failed to provide adequate communication in the native language of a resident, who speaks an Arabic dialect, as required by their own policy. The facility's policy on translation and interpretation services was not implemented effectively. Staff members resorted to using hand gestures and Google Translate, which were not in accordance with the facility's communication policy. Additionally, the facility relied on a family member to translate, which could lead to inconsistent and inaccurate communication. The facility's policy outlined several methods for providing competent oral translation, including using trained staff interpreters, contracted interpreter services, and telephone interpretation services, none of which were utilized for this resident. Interviews with staff revealed a lack of awareness and training regarding the use of translation services. The Social Services Director, who speaks Arabic, was the only staff member available to assist, but only during day shifts. A Certified Nursing Assistant and a Licensed Nurse admitted to not using the language line and were unaware of its availability. The Director of Nursing claimed that staff were trained to use the language line, but documentation showed that the CNA and LN involved did not receive such training. Furthermore, there was no evidence provided to confirm the use of telephonic translation services for the resident during the investigation.
Failure to Implement Infection Control Program
Penalty
Summary
The facility failed to implement their infection control program when two staff members did not wear proper full personal protective equipment (PPE) while providing care to residents who tested positive for COVID-19. Specifically, two Certified Nursing Assistants (CNAs) were observed inside a COVID-positive resident's room without wearing face shields or goggles, despite a poster on the wall indicating that full PPE, including face shields or goggles, was required. Additionally, one CNA improperly discarded a used N95 mask by placing it on top of the PPE cart instead of disposing of it properly. Both CNAs admitted to not wearing face shields or goggles while providing care, with one CNA stating that there were no available face shields in the PPE cart at the time. During interviews, both CNAs confirmed that they were designated to provide care to COVID-positive residents and acknowledged the importance of wearing full PPE, including face shields, to protect against splashes and prevent the spread of infection. A Licensed Nurse (LN) also confirmed that the expectation was for staff to discard used N95 masks properly and to wear full PPE while providing care to COVID-positive residents. The failure to adhere to these infection control protocols had the potential to contaminate supplies and spread infection among staff and residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 668 citations issued within 25 miles in the last 12 months — including the 3 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 La Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkway Hills Nursing & Rehabilitation | 0 mi | ★★★★★ | 34 | 0 |
| Country Manor La Mesa Healthcare Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Grossmont Gardens Healthcare Center | 0.6 mi | — | 22 | 0 |
| Grossmont Hospital D/p Snf | 1.2 mi | ★★★★★ | 0 | 0 |
| Community Care Center | 1.2 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.