Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Asistencia Villa Healthcare Center during CMS and state inspections, most recent first.
A facility failed to follow infection control practices for multiple residents when oxygen tubing was left open to air instead of stored in a bag, two urinary catheter drainage bags were resting on the floor, a CNA provided high-contact care to a resident on EBP without a gown, and an LVN used the same glucometer for several residents without disinfecting it between uses. Staff and the DON/CM-IPN acknowledged the practices did not follow facility policy.
Call light and shower bed equipment were not maintained in working condition. In one shower stall, the wall-mounted call light could not be activated because the pull cord was missing, and the FMD stated the call system should be available in every shower and restroom. In addition, a shower bed used to bathe and transport a resident had missing locking pins on both side rails, leaving the rails unable to stay upright; CNAs reported using the bed with the rails down and sometimes improvised with a spoon handle.
An IV fluid bag for a resident was running without required label information, including the medication name, infusion rate, date, time, expiration date, or staff initials. In addition, a treatment cart and a medication cart were observed unlocked and unattended, and RN, LVN, and DON statements confirmed the carts should have been locked when not in use.
Inaccurate PASRR screening was identified for two residents. One resident’s PASRR did not include cerebral palsy, and another resident’s PASRR did not reflect diagnoses of anxiety, bipolar disorder, and major depressive disorder. The MDSC acknowledged the screenings were not accurately completed or corrected on admission, and the DON acknowledged the documentation was not accurate and the facility policy was not being followed.
A resident missed multiple ordered doses of Heparin and Keflex because the meds were not available when needed. The MAR and progress notes showed the doses were not given, and the DON acknowledged there was no documented evidence that the physician was notified of the missed doses. The resident had thrombocytosis, Guillain-Barre Syndrome, hereditary motor and sensory neuropathy, and scalp cellulitis treated with Keflex.
A resident with a Foley catheter was observed sitting in a wheelchair with the drainage bag left next to her instead of below bladder level after returning from rehab. The LVN confirmed the bag was not positioned properly, the COTA said she thought she had placed it lower, and the DON stated staff were responsible for keeping the bag below the bladder to prevent backflow and UTIs.
A resident with DM, CKD, dehydration, and Alzheimer’s disease had poor oral intake, refused meals, and lost weight from 130 to 120 pounds. Staff offered alternate foods and supplements, but weekly weights were not completed, and the DON confirmed no care plan was in the chart to address the resident’s weight loss. The RD noted behavioral issues such as spitting out food and meds, and the resident had orders for a CCHO soft and bite-sized diet, thin liquids, daily snacks, and Nepro or equivalent.
Medication administration and controlled substance documentation were not completed as ordered. One resident did not receive scheduled levothyroxine because the dose was unavailable, and another resident received sevelamer carbonate without meals despite a physician order to give it with meals. In addition, a controlled substance shift-to-shift count log for one medication cart had a missing nurse signature, and the DON confirmed the facility policy was not followed.
Medication errors exceeded the allowed rate after surveyors observed 2 errors in 26 opportunities. One resident did not receive ordered levothyroxine because the medication was unavailable at the scheduled time, and another resident received sevelamer carbonate without meals even though it was ordered to be given with meals. The DON confirmed the medication should have been available and administered as ordered.
A resident received a built-up spoon with no end cap on the handle, and water pooled inside the hollow handle spilled onto her food during lunch. A nearby resident reported the same issue had happened repeatedly with his own built-up spoon, and a CNA confirmed the utensil had an open hollow handle. The DON and RD stated adaptive eating devices should be in good working order and not be given to residents if broken or needing repair.
A resident with mobility and gait issues left the facility without staff knowledge and was missing for five hours before being found at a nearby building. The resident did not have authorization to leave, and staff interviews confirmed that required supervision was not maintained, resulting in the resident's unsupervised exit.
A resident with a history of cardiac arrest received a double dose of Metoprolol Tartrate when two LVNs each administered the medication, due to a lack of immediate documentation and failure to verify assignments. The medication was present in both nurses' carts, and only one administration was recorded in the MAR, contrary to facility policy requiring immediate documentation.
Two residents with significant medical needs, including respiratory failure and paralysis, experienced delays in receiving assistance with ADLs such as changing and personal hygiene. Both residents reported waiting extended periods for help, particularly during night shifts, and staff interviews confirmed that care was sometimes delayed due to insufficient staffing. Facility policy requires timely ADL support, but this was not consistently provided.
A resident with acute respiratory failure did not receive a scheduled dose of Pirfenidone due to a medication error at the facility. An LVN mistakenly disposed of the medication, believing it was discontinued, leading to its unavailability for administration. The DON confirmed the error, acknowledging that staff did not follow the facility's policy on medication error reporting.
The facility failed to maintain a sanitary kitchen, with observations of sticky residues, food crumbs, and trash in various areas, including a juice dispenser cabinet and under the steam table. An industrial mixer had food residue, and the ice machine had brown buildup. Staff acknowledged these areas should be clean, aligning with facility policies and FDA codes.
The facility failed to track and document staff COVID-19 vaccination status, as required by its policy. The ICP nurse was unaware of the responsibility to maintain such documentation until reviewing the facility's policy. The DON confirmed the lack of tracking, which could increase the risk of COVID-19 exposure to the 95 residents.
A leaking countertop water dispenser in the facility was not repaired, leading to standing water accumulation. Staff acknowledged the issue, and dietitians expected prompt repair. The facility's maintenance policy and FDA guidelines emphasize the need for equipment to be in good repair to prevent health risks.
A resident experienced a significant change in condition, transitioning from gastric tube feeding to an oral diet, but the facility failed to complete a Significant Change of Status Assessment (SCSA) within the required 14-day period. The MDS nurse did not update the assessment, resulting in a 68-day delay, leaving the resident's care plan outdated and not reflective of their current needs.
A facility failed to accurately complete the MDS assessment for a resident using mittens and an abdominal binder as restraints. Despite physician orders and observations confirming the use of these restraints, the Quarterly MDS assessment did not reflect this, violating the facility's policy on assessment accuracy. The DON and MDS Nurse acknowledged the oversight.
A medication cart in the 200's hall was found unsanitary with a yellow moist buildup in the bottom drawer containing over-the-counter medications. Both an LVN and the ICP nurse confirmed the unsanitary condition, which violated the facility's policy requiring clean and safe medication storage. The DON acknowledged the policy was not followed.
A facility failed to implement its antibiotic stewardship policy for a resident, as the ICP nurse did not accurately assess and collect necessary data to ensure appropriate antibiotic use. The resident, admitted with metabolic encephalopathy and ventilator-associated pneumonia, was prescribed Merrem and Zyvox for sepsis. However, the Surveillance Data Collection Form was incomplete, and the Loeb's criteria were not filled out, leaving it unclear if the antibiotics were used for a true infection. Interviews revealed the facility did not follow its policy, resulting in a deficiency.
A resident with polyneuropathy was mistakenly given Methocarbamol after it was discontinued, due to the facility's failure to remove the medication from the cart as per policy. The error was identified by an LVN and the resident's grandson. The facility's policy requires immediate removal of discontinued medications to prevent such errors.
Two residents with chronic conditions reported significant delays in call light response times, ranging from 10 minutes to two hours, affecting their daily living activities. Despite care plans indicating the need for prompt assistance, the facility failed to adhere to its policy, leading to residents waiting in soiled diapers and experiencing false documentation of care refusals.
A resident with a history of falls, seizures, and dementia fell and sustained a subdural hematoma due to inadequate supervision. The resident was found unsupervised at the nurse's station and fell from his wheelchair, hitting his head. The facility's policies on accident prevention and resident safety were not followed, as confirmed by the ADON.
Infection Control Lapses With Respiratory Equipment, Catheter Bags, EBP, and Glucometer Use
Penalty
Summary
The facility failed to establish and maintain effective infection prevention and control practices for multiple residents when respiratory equipment, urinary catheter drainage systems, enhanced barrier precautions, and shared blood glucose testing equipment were not handled according to facility policy. The report identified deficiencies involving residents with oxygen therapy, indwelling urinary catheters, and residents requiring enhanced barrier precautions, as well as repeated use of a glucometer without disinfection between residents. For a resident with acute respiratory failure, respiratory failure with hypoxia, and COPD, an oxygen concentrator was observed in the room with the oxygen tubing coiled and resting on top of the concentrator, open to air and not stored inside a respiratory equipment bag. The tubing was not connected to the resident at the time of the observation. The CNA present stated the tubing should be stored inside a respiratory equipment bag when not in use for infection control purposes and that leaving it open to air could result in contamination. The DON later confirmed the staff did not follow the facility's respiratory infection prevention policy, which directed that oxygen cannula and tubing used PRN be kept in a plastic bag when not in use. Two residents with urinary catheters were observed with catheter drainage bags hanging off the bed frame and resting on the floor. The RN stated the bags were not supposed to be on the floor for infection control purposes. The CM/IPN later confirmed the catheter care policy was not followed and stated the tubing and drainage bag should be kept off the floor to prevent bacteria from re-entering the urinary bag. In another instance, a CNA entered a resident's room where enhanced barrier precautions were posted and assisted with dressing, emptying the urinal drainage bag, and transferring the resident without wearing a gown. The CNA stated she was not aware the resident was on enhanced barrier precautions until after the interaction. The DON stated staff assisting residents on enhanced barrier precautions were supposed to wear a gown and gloves during transferring, changing, and assisting with toileting or other high-contact care activities. A LVN was also observed performing blood sugar checks on five residents using the same glucometer without cleaning or disinfecting it between uses. The LVN acknowledged she did not sanitize the glucometer after use for those residents and stated it should have been sanitized after each use. The CM/IPN confirmed the facility's policy for cleaning and disinfection of resident-care items and equipment was not followed and stated reusable items should be cleaned and disinfected between residents.
Call Light and Shower Bed Equipment Not Maintained
Penalty
Summary
The facility failed to ensure the call light system was maintained in safe and working condition in one of two shower rooms. During observation in Shower room A, one of the two shower stalls had a wall-mounted call light that could not be activated because there was no pull cord connected to it and no button to press. The Facility Maintenance Director stated residents and staff were supposed to be able to call for assistance by using a pull cord, that the call system was supposed to be available for every shower and toilet area, and that he did not know why the pull cord was missing. The Administrator stated every shower and every restroom in the facility should have a pull cord to activate the call system. The Director of Nursing stated the pull cords for the call system should be present on all call lights and in operating condition. The facility policy titled Nurse's Call System stated the facility was to maintain building systems in good working order and to replace defective light bulbs, buzzers, and cords, and to check that call systems in toilets, bathrooms, and showers were properly grounded and working. The facility also failed to keep one of two shower beds in safe working condition. Resident 62 stated the shower bed had non-functioning side rails and that it had been that way for a couple months. During observation, CNA 3 used the shower bed to transport Resident 56 from the shower room to the resident's room, and the side rails were down because both locking pins were missing. CNA 3 stated the rails were normally held upright by pins, but both pins were missing, and she sometimes used a plastic spoon handle in the pin holes to keep the rails upright. CNA 4 stated the shower bed had not had pins for approximately one month. The Facility Maintenance Director stated he had been made aware a few days earlier that the pins were missing and had not yet fixed the bed because he was waiting to find the correct pin size.
Unsecured medication carts and improperly labeled IV fluid
Penalty
Summary
Medication storage was not kept secured and an IV fluid bag was not labeled in accordance with facility policy and accepted professional principles. The facility failed to ensure that drugs and biologicals were stored in locked compartments or otherwise secured, and failed to ensure that an IV infusion for a resident was labeled with required information when it was hung and running in the resident’s room. Resident 63 was admitted with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, dehydration, and Alzheimer’s disease. During observation, the resident was in bed with an IV infusion actively running at 100 mL per hour. The IV bag contained 0.9% Normal Saline and had an orange label showing 100 cc, but the label did not include the medication name, infusion rate, date, time, expiration date, or staff initials. RN 1 confirmed the missing information and stated the nurse who hung the IV should have included all required labeling information. The DON reviewed the facility’s infusion therapy product label policy and confirmed the IV bag labeling did not meet policy requirements. The facility also left medication and treatment carts unsecured. One treatment cart in the 400 hall was observed unlocked and unattended with five drawers containing supplies and medications used for wound treatment, and RN 2 confirmed treatment carts were supposed to be locked when not in use. A medication cart at station 1 was also observed unlocked and unattended, and LVN 1 verified it was unlocked and stated carts are expected to remain locked to keep residents from opening them. The DON confirmed both carts should have been locked and stated the policy was not followed.
Inaccurate PASRR Screening for Two Residents
Penalty
Summary
PASRR screening was not completed accurately for two sampled residents. One resident was admitted with diagnoses including major depressive disorder, anxiety disorder, PTSD, and cerebral palsy, but the PASRR Level I screening dated July 14, 2023, marked “NO” for intellectual/developmental disability or related conditions and did not include cerebral palsy in that section. The record showed the screening resulted in a Level I positive status with submission for a Level II assessment. During interview, the MDS Coordinator stated the PASRR did not reflect the resident’s existing diagnosis of cerebral palsy and acknowledged the facility did not accurately screen or correct the PASRR on admission. A second resident was admitted with diagnoses including major depressive disorder, bipolar disorder, and generalized anxiety, but the PASRR Level I screening dated October 6, 2025, marked “NO” for serious mental illness and did not reflect the resident’s anxiety, depression, or bipolar disorder. The screening resulted in a Level II not required status. During interview, the MDS Coordinator stated the PASRR did not accurately reflect the resident’s diagnoses and acknowledged the facility did not accurately screen or correct the PASRR on admission. The DON reviewed the facility’s documentation policy and acknowledged the PASRRs were not accurate and that the policy was not being followed.
Missed Heparin and Keflex Doses Without Physician Notification
Penalty
Summary
Resident 10 did not receive medications as ordered by the physician, and the physician was not informed of the missed doses. Resident 10 was admitted with diagnoses including thrombocytosis, Guillain-Barre Syndrome, and hereditary motor and sensory neuropathy. She stated during interview that she had been receiving Heparin and Keflex a few weeks earlier but missed some doses because the facility did not have the medications available. She also stated the Keflex was being used to treat an infection on her scalp. The physician ordered Heparin Sodium injection 5000 unit/ml, 0.5 milliliter subcutaneously every 12 hours for DVT prophylaxis. The MAR showed that Resident 10 did not receive the 9:00 AM and 9:00 PM doses of Heparin on November 28, 2025, and did not receive the 9:00 AM dose on November 29, 2025. A progress note documented that the medication was not here and that staff would continue to follow up with pharmacy. The DON acknowledged there were three missed doses of Heparin and stated there was no documented evidence that the physician was notified of the missed doses. The physician also ordered Keflex 500 mg by mouth every 6 hours for scalp cellulitis for 7 days. The MAR showed Resident 10 did not receive the 6:00 AM and 12:00 PM doses on November 29, 2025. A progress note stated the medication was waiting for pharmacy delivery, that the original order had been sent to reorder, and that the e-kit had none available. The DON and consultant pharmacist stated the facility should have had the medication available as ordered, and the DON acknowledged there was no documented evidence that the physician was notified of the two missed Keflex doses.
Foley Drainage Bag Left in Wheelchair Above Bladder Level
Penalty
Summary
The facility failed to ensure appropriate catheter care for one resident with a Foley catheter when the urinary drainage bag was found in the resident’s wheelchair instead of being positioned below the level of the bladder. Resident 10 was admitted with diagnoses including urinary retention, multiple rib fractures, gait and mobility abnormalities, and dementia. During a concurrent observation and interview, Resident 10 was sitting in her wheelchair in her room with the Foley drainage bag next to her in the wheelchair and approximately 300 mL of urine in the bag. Resident 10 stated she had returned from the rehab gym about 40 minutes earlier and that a staff member had brought her back to her room in the wheelchair and left the drainage bag there. During the same observation, LVN 5 acknowledged the drainage bag was next to the resident in the wheelchair and stated it was supposed to be below the level of the bladder but was not. LVN 5 also stated the bag needed to be lower than the bladder to ensure urine could not backflow into the bladder. COTA 1 stated she was the staff member who brought the resident back from the rehab gym and said she thought she had placed the Foley drainage bag lower. The DON stated it was staff responsibility to ensure the Foley drainage bag was placed below the bladder to prevent backflow of urine and urinary tract infections. The facility policy stated the drainage bag should be positioned lower than the bladder at all times.
Failure to Initiate Care Plan for Resident Weight Loss
Penalty
Summary
The facility failed to ensure a care plan was initiated to address Resident 63’s weight loss. Resident 63 was admitted with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, dehydration, and Alzheimer’s disease. During observation, the resident was awake in bed and responded by nodding yes or no, but indicated he was not eating his meals and did not like the food provided. During lunch, a CNA assisted the resident and reported he had consumed about 50% of breakfast but refused lunch; the CNA stated staff offer alternate food items and notify licensed nurses when residents have poor intake or refuse meals, and an LVN offered fruit and milk, which the resident also refused. Record review showed Resident 63’s weight decreased from 130 pounds on October 6, 2025, to 120 pounds on December 1, 2025, and the DON confirmed the resident should have had weekly weights but they were not done. A change in condition evaluation dated November 13, 2025 documented weight loss of 12 pounds in 3 months and noted no RD recommendation at that time. The resident had orders for a CCHO soft and bite-sized diet, thin liquids, daily snacks, and Nepro or equivalent daily. The RD stated nursing staff reported behavioral issues including spitting out food and medications, and the DON confirmed no care plan addressing the resident’s weight loss was located in the clinical record. The facility policy stated care planning for weight loss or impaired nutrition should be a multidisciplinary effort and address causes, goals, benchmarks, and monitoring parameters.
Medication Administration and Controlled Substance Record Deficiencies
Penalty
Summary
Medication administration was not completed as ordered for two residents during observation and record review. One resident had an order for Levothyroxine Sodium 175 mcg by mouth in the morning at 6:30 AM for hypothyroidism, but the LVN was unable to locate the dose on the medication card and the medication was not available at the time of administration. The LVN stated that when a medication is not available, the RN supervisor is notified to check for emergency or cycle medications and to notify the physician, and confirmed that the Levothyroxine was not administered as ordered. Another resident with end stage renal disease, abnormal posture, and dependence on renal dialysis had an order for Sevelamer Carbonate 800 mg, four tablets by mouth three times a day for hyperphosphatemia, to be taken with meals. During medication pass observation, the LVN administered the medication before breakfast and acknowledged that it should have been given with meals. The DON reviewed the physician order and the facility’s Medication Administration-General Guidelines and stated the medication should have been given as ordered. Controlled medication records were also not maintained accurately for one medication cart. The Controlled/Narcotic Emergency Kit Shift to Shift Check for Licensed Nurses showed a missing signature for the outgoing nurse during one shift change. The LVN confirmed the missing signature and stated the expectation is for two nursing staff to count and sign the narcotic log at every shift change. The DON reviewed the facility’s controlled medication storage policy and stated the policy was not followed.
Medication Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent after surveyors observed 2 medication errors out of 26 opportunities, resulting in a 7.69 percent error rate. One error involved a resident admitted with metabolic encephalopathy, type 2 diabetes mellitus with complications, and hypertensive heart disease with heart failure, who had an order for Levothyroxine Sodium 175 mcg by mouth in the morning for hypothyroidism. During a medication pass observation, the LVN reviewed the medication card but could not locate the dose, and the medication was not available at the scheduled time and was not administered as ordered. The LVN stated that when a medication is not available, the RN supervisor is notified to check for emergency or cycle medications and contact the physician, and confirmed the Levothyroxine was not available at the time of the scheduled dose. The second error involved a resident with end stage renal disease, abnormal posture, and dependence on renal dialysis, who had an order for Sevelamer Carbonate 800 mg, 4 tablets by mouth three times a day with meals for hyperphosphatemia. During observation, the LVN prepared and administered the medication without meals, stating breakfast was served later and that she was unable to give it with meals because of a time conflict. On follow-up, the LVN acknowledged the medication should have been given with meals. The DON reviewed the facility policies on medication ordering and administration and stated nursing staff are responsible for ensuring prescribed medications are available and that the medication should have been given as ordered.
Built-Up Spoon Provided With Water in Hollow Handle
Penalty
Summary
The facility failed to ensure eating utensils were kept in a clean and sanitary condition when a resident received a built-up spoon with water pooled inside the hollow handle during lunch. During a concurrent observation and interview in the dining room, the resident stated she had received a tray of food, but when she tried to use her built-up spoon, the spoon was missing the cap on the end of the handle and water spilled out of the handle onto her food. She stated this had happened on at least five previous occasions when she received the same type of spoon with meals. A second resident seated nearby stated he also required a built-up spoon and had repeatedly received spoons without an end cap, with water pooled in the handle spilling onto his food when he used it. A CNA confirmed the resident was eating a sandwich instead of the regular meal because the spoon had no cap and water spilled onto the food, and showed the spoon with a large hollow handle and an open end approximately the size of a quarter. The DON stated adaptive devices not in good repair should be disposed of and not provided to residents, and the RD stated adaptive devices should be safe to use and should not be given to residents if broken or needing repair. Facility policies stated adaptive devices should be in good working order and utensils should be kept clean and in good repair.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for one of four sampled residents when the resident left the facility without staff knowledge and was missing for five hours. The resident, who had diagnoses including spinal stenosis of the cervical region and abnormalities of gait and mobility, was last seen by an LVN in the hallway around 5:00 AM. Shortly after, staff noticed the resident was not in his room during rounds, prompting a search and notification of the supervisor. The resident was eventually found at an adjacent facility and taken to the hospital. Record review and interviews revealed that the resident did not have authorization or a physician's order to leave the facility. The facility's policy requires constant supervision for residents not authorized to leave, and elopement assessments are conducted for those at risk. The administrator acknowledged that insufficient supervision contributed to the incident, as the resident was able to exit the building without staff awareness.
Double Dosing of Blood Pressure Medication Due to Documentation and Assignment Errors
Penalty
Summary
A deficiency occurred when a resident with a history of cardiac arrest was administered a double dose of Metoprolol Tartrate, a blood pressure medication, by two different licensed vocational nurses (LVNs). The first LVN administered the medication but was interrupted before documenting the administration. Upon returning, the LVN discovered that a second LVN had also administered the same medication, mistakenly believing the resident was assigned to him. The second LVN did not verify his assignment prior to giving the medication, and both LVNs found that the medication was present in both of their medication carts. Review of the Medication Administration Record (MAR) showed that only one administration was documented, and the facility's policy required immediate documentation after medication administration. Both the Administrator and the Director of Nursing confirmed that the policy was not followed, and the staff failed to adhere to the five rights of medication administration and proper documentation procedures.
Delayed Assistance with ADLs for Dependent Residents
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents who were clinically compromised and dependent on staff for care. Resident 1, with diagnoses including chronic respiratory failure, morbid obesity, dependence on a respirator, and quadriplegia, reported having to wait a long time to be changed on multiple occasions. The care plan for this resident identified problems with ADL decline and set goals for improvement in grooming, dressing, and toileting. Resident 2, diagnosed with chronic respiratory failure, COPD, paraplegia, and respirator dependence, also reported waiting a long time for help with changes, particularly at night. The care plan for this resident noted a self-care performance deficit and total dependence on staff for personal hygiene and oral care. Interviews with staff confirmed that delays in providing care occurred, especially when staffing was insufficient. A CNA acknowledged that it sometimes took a while to attend to residents' needs due to lack of help. The DON stated that nursing staff are expected to provide timely assistance and confirmed that residents' needs should have been met promptly. Review of the facility's policy indicated that residents should receive care to prevent decline in ADLs unless clinically unavoidable, and that appropriate care should be provided in accordance with the care plan.
Medication Error Due to Miscommunication and Disposal
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding medication error and adverse drug reaction reporting, resulting in a significant medication error for one resident. The resident, who was admitted with a diagnosis including acute respiratory failure, did not receive a scheduled dose of Pirfenidone, a medication prescribed for interstitial lung disease, on December 21, 2024. This omission occurred because a Licensed Vocational Nurse (LVN) mistakenly disposed of the medication, believing it had been discontinued. The error was realized later that day, but the medication was not available for administration. The Director of Nursing (DON) confirmed that the medication was not administered due to its unavailability, as it had been accidentally discarded. Another LVN corroborated this account, stating that the medication was not available for the scheduled dose. The facility's policy defines a medication error as an omission of a vital medication due to an error in prescribing, dispensing, or administering. The DON acknowledged that the staff did not follow the established policy, leading to the medication error.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by several observations. A cabinet storing a juice dispenser had a sticky residue on its handle, and inside the cabinet, there was a red juice spill. Additionally, the area under the steam table contained food crumbs and trash, and there was food residue around the floor sink. These conditions were noted during observations and confirmed through interviews with staff, who acknowledged that these areas should be kept clean. Further observations revealed that the industrial mixer was stored with white food residue on its exterior, which was covered by a black plastic bag. This was confirmed during an interview with the Registered Dietitian Nutritionists, who stated that the mixer should be cleaned thoroughly before being covered. The facility's policy on sanitization, as well as the FDA Federal Food Code, emphasize the importance of maintaining non-food contact surfaces in a clean state to prevent the accumulation of soil residues. Additionally, the ice machine in the kitchen had a brown buildup in the area where ice is formed. This was observed and confirmed by the facility's Maintenance Director, who stated that the area should be kept clean. The facility's policy on ice machines and the FDA Federal Food Code require regular cleaning to prevent the development of slime, mold, or soil residues. These deficiencies had the potential to attract pests and cause foodborne illness to the residents consuming meals prepared in the facility.
Failure to Track and Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to implement its infection control program to prevent the spread of COVID-19 by not maintaining any tracking and documentation of staff COVID-19 vaccination status. During an interview and record review, the Infection Control Preventionist (ICP) nurse was unable to provide documentation indicating a tracking system for staff members' COVID-19 vaccination status. The ICP nurse admitted to being unaware of her responsibility to maintain such a system until she reviewed the facility's Policy and Procedure on COVID-19 Vaccination for Staff. The Director of Nursing (DON) confirmed that there was no tracking and documentation of staff COVID-19 vaccination status. The facility's policy, revised in January 2024, required the infection preventionist to maintain a tracking worksheet of staff members and their vaccination status, including specific details such as staff name, job title, vaccination status, and documentation of informed consent. The DON acknowledged that the facility did not follow this policy, which had the potential to cause harm to the 95 residents by increasing the risk of exposure and spread of the COVID-19 virus.
Leaking Water Dispenser Not Repaired
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as evidenced by a leaking countertop water dispenser. During an observation, it was noted that the water dispenser was leaking and collecting standing water in the drain beneath it. This issue was confirmed during an interview with a staff member who acknowledged that the dispenser was not in use and required repair. Further interviews with two Registered Dietitian Nutritionists revealed that there was an expectation for the water dispenser to be fixed promptly. A review of the facility's maintenance policy indicated that the maintenance department is responsible for ensuring all equipment is kept in a safe and operable condition. Additionally, the FDA Federal Food Code emphasizes the importance of maintaining equipment in good repair to prevent health risks to consumers.
Failure to Complete SCSA for Resident After Significant Change
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) for a resident within the required 14-day period following a significant change in the resident's condition. The resident, who was initially receiving nutrition through a gastric tube, had the tube removed and transitioned to an oral diet. This change in the nutrition route and the level of eating assistance required an updated assessment to reflect the resident's current status. However, the MDS nurse did not complete the SCSA, which was due by August 10, 2024, resulting in a delay of 68 days without the assessment being completed. The deficiency was identified during a review of the resident's records and interviews with the Director of Nursing (DON) and the MDS nurse. The resident's clinical records indicated a change from dependent gastric tube feeding to oral partial/moderate assistance for eating, but the last MDS assessment was a quarterly assessment completed on July 18, 2024. The facility's policy requires a comprehensive assessment when there is a significant change in a resident's condition, but this was not adhered to, leading to the resident's care plan not being updated to reflect the current status.
Inaccurate MDS Assessment for Restraint Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were completed accurately for a resident, specifically regarding the use of restraints. Resident 68, who was admitted with diagnoses including metabolic encephalopathy and a tracheostomy, was observed wearing mittens and an abdominal binder to prevent interference with medical equipment. However, the Quarterly MDS assessment did not reflect the use of these physical restraints, as it was not coded under the relevant section for restraints and alarms. Interviews with the Director of Nursing (DON) and the MDS Nurse confirmed that the orders for the use of mittens and an abdominal binder were present, but the MDS assessment failed to capture this information. The facility's policy on certifying the accuracy of resident assessments was not followed, as the assessment did not accurately reflect the resident's status during the observation period. The MDS Nurse acknowledged that the restraints should have been coded, and the facility's failure to adhere to the policy was confirmed during the review.
Unsanitary Medication Cart Found in Facility
Penalty
Summary
The facility failed to store all drugs and biologicals in accordance with currently accepted professional principles and its own policies and procedures. During an observation on October 16, 2024, a medication cart on the 200's hall was found to be unsanitary. Specifically, the left bottom drawer of the cart, which contained as-needed over-the-counter medications, had a yellow moist buildup. This was confirmed by a Licensed Vocational Nurse (LVN 2) who acknowledged the unsanitary condition of the drawer. Further inspection by the Infection Control Preventionist (ICP) nurse confirmed the presence of the yellow buildup. The ICP nurse emphasized the importance of keeping medication carts clean to maintain medication efficacy and prevent contamination. The Director of Nurses (DON) reviewed the facility's policy on medication storage, which mandates that nursing staff maintain medication storage areas in a clean, safe, and sanitary manner. The DON acknowledged that the policy was not followed, leading to the deficiency.
Failure to Implement Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to implement its policy and procedure on antibiotic stewardship for one of the residents, identified as Resident 47, who was reviewed for antibiotic use. The Infection Control Preventionist (ICP) nurse did not accurately assess and collect data to indicate the rationale and common clinical conditions necessary to ensure the appropriate use of antibiotic therapy for this resident. This oversight had the potential to place Resident 47 at risk for adverse events, including the development of antibiotic-resistant organisms, due to unnecessary or inappropriate antibiotic use. Resident 47 was admitted to the facility with diagnoses including metabolic encephalopathy and ventilator-associated pneumonia. A review of the resident's physician's orders revealed that antibiotics Merrem and Zyvox were prescribed for sepsis. However, during the review, it was found that the Surveillance Data Collection Form used to monitor and collect data on antibiotic use was incomplete. Key fields such as the diagnosis, culture, and type of infection were left blank, and the Loeb's minimum criteria for initiating antibiotics were not filled out, leaving it unclear whether the antibiotics were used for a true infection. Interviews with the ICP nurse and the Director of Nursing (DON) revealed that the facility's policy on antibiotic stewardship was not followed. The policy required that all clinical infections treated with antibiotics undergo review by the infection preventionist, and that antibiotic usage and outcome data be collected and documented. However, the ICP nurse admitted to not conducting the necessary analysis and review to confirm whether Resident 47 had a true infection, which was a critical step in ensuring the appropriate use of antibiotic therapy. The facility's failure to adhere to its own policy and procedure resulted in a deficiency in antibiotic stewardship practices.
Failure to Remove Discontinued Medication Leads to Administration Error
Penalty
Summary
The facility failed to adhere to its policy and procedure for the removal of discontinued medication from the medication cart, leading to a medication error involving a resident. The resident, who was admitted with a diagnosis of polyneuropathy, was administered Methocarbamol, a muscle relaxant, despite the medication having been discontinued. The error was identified when a licensed vocational nurse (LVN) administered the medication and later realized the mistake, which was also pointed out by the resident's grandson. The registered nurse supervisor and the facility administrator confirmed that the medication should have been removed from the cart immediately upon receiving the discontinuation order. However, the medication remained in the cart due to oversight, contributing to the error. The facility's policy, as outlined in their Discontinued Medications - Disposal policy and procedure manual, mandates the immediate removal of discontinued medications to prevent such errors, but this protocol was not followed in this instance.
Delayed Call Light Response for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for answering call lights in a timely manner, which affected two residents. Resident 1, who has chronic obstructive pulmonary disease and no mental impairment, reported that the average response time for assistance was 20 minutes. Additionally, Resident 1 mentioned instances of false documentation by staff regarding his refusal to shower. Resident 2, diagnosed with chronic respiratory failure with hypoxia and also without mental impairment, reported that call light response times ranged from 10 minutes to two hours, with longer delays during nighttime and shift changes. Resident 2 experienced waiting in soiled diapers for up to two hours. The care plans for both residents indicated deficits in activities of daily living, requiring prompt assistance with tasks such as personal hygiene, dressing, and toilet use. Despite these documented needs, the facility did not ensure that call lights were answered promptly, as confirmed by interviews with the residents and a Certified Nursing Assistant. The assistant director of nursing acknowledged the issue but did not provide comments on the findings. The facility's policy, revised in October 2010, emphasized the importance of responding to residents' requests and needs, which was not followed in these cases.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision to prevent avoidable accidents, resulting in a resident falling and sustaining a subdural hematoma. Resident 4, who had a history of repeated falls, seizures, dementia, and gait abnormalities, was found unsupervised and fell from his wheelchair, hitting his head. The incident occurred while the resident was sitting at the nurse's station, and the fall was unwitnessed. Following the fall, the resident reported head pain and dizziness and was subsequently transferred to the emergency department, where a CT scan revealed bilateral subdural hematomas. Interviews with staff and review of the resident's care plan and clinical records indicated that the resident had not been adequately supervised, despite being identified as at risk for falls. The facility's policies on accident prevention and resident safety were not followed, as acknowledged by the Assistant Director of Nursing (ADON). The ADON confirmed that more supervision should have been provided to the resident to prevent the accident, highlighting a failure to adhere to established safety protocols and procedures designed to protect residents from avoidable accidents.
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What surveyors actually found near you
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Redlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Gardens Health Care Center | 1.1 mi | ★★★★★ | 18 | 0 |
| Loma Linda Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
| Brookside Healthcare Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Totally Kids Rehabilitation Hospital - D/p Snf | 1.6 mi | ★★★★★ | 10 | 0 |
| Madison Grove Post Acute | 1.9 mi | ★★★★★ | 17 | 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.