Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beach Creek Post-acute during CMS and state inspections, most recent first.
Failure to Provide Respiratory Care per Orders: Multiple residents had oxygen, nebulizer, and suction equipment that did not match physician orders or facility P&P. Surveyors observed residents receiving oxygen at incorrect LPM settings, one resident with no oxygen order, another resident using a roommate’s tubing and concentrator, and several residents with undated or improperly stored respiratory supplies, including nebulizer masks, set-up bags, and suction tubing.
Kitchen Food Safety and Sanitation Deficiencies: Surveyors observed multiple opened food items without proper labels or dates, including items connected to the juice dispenser, frozen veggie patties, and bread. They also found residue in a utensil drawer and on the can opener, heavily marred cutting boards, a melted spatula handle, a dented can in rotation, a dirty resident food refrigerator, expired chlorine test paper for the low-temp dishwasher, and a wet blender being used for puree prep.
The facility failed to properly monitor and document psychotropic medication use for multiple residents. Records showed missing orthostatic BP checks for antipsychotics, absent or inaccurate behavior summaries, no documented nonpharmacological interventions before PRN psychotropics, and mismatched diagnoses or indications for certain meds such as olanzapine, aripiprazole, Cymbalta, Remeron, lorazepam, quetiapine, sertraline, and temazepam. Staff interviews confirmed the gaps in MAR, care plan, and behavior documentation.
Failure to Respond to Low BP: A resident with no decision-making capacity had a BP of 76/51 mmHg, followed by additional low readings, but the record did not show an intervention or clinician notification between the low BP readings. Later, the resident became lethargic and slow to respond, 911 was called, and the resident was transported to the hospital with septic shock.
Failure to Reposition a Resident With a Pressure Injury. A resident with decreased mobility and incontinence developed worsening coccyx/sacral skin breakdown that progressed to an unstageable pressure injury with slough. The care plan called for repositioning every 2 hours and PRN, but documentation showed multiple missed turns before and after the injury, and the resident stated staff did not assist or remind her to turn. The LVN and DON acknowledged the resident’s risk factors and the expected turning/repositioning interventions.
A facility failed to follow care plan interventions for bilateral floor mats for two residents at fall risk. One resident with confusion, impaired mobility, weakness, and no decision-making capacity was observed in bed with only one floor pad in place, while staff confirmed both sides should have pads. Another resident with poor safety awareness, unsteady gait, wandering, and a recent fall was observed with one floor pad folded up against the bed, and staff stated the pads were not always used consistently.
Pain medications were not consistently administered according to orders or preceded by documented non-pharmacologic interventions for three residents. One resident received PRN opioid medication for a pain level that should have triggered acetaminophen instead, another received PRN opioid and Tylenol outside the ordered pain ranges, and a third received scheduled Norco and a lidocaine patch even when pain was documented as zero. The MARs lacked documentation showing that ordered non-pharmacologic measures were attempted before these pain medications were given.
A resident with ESRD on hemodialysis had orders for I&O every shift and a 1200 ml/day fluid restriction, but records showed repeated days when intake exceeded the prescribed limits. Staff documented TI amounts that did not match the actual nursing and dietary totals, and an RN confirmed one shift was charted as 400 ml instead of the verified 420 ml because she was in a rush.
Failure to follow ordered hold parameters for BP medications affected two residents. One resident received carvedilol on multiple occasions even though the documented SBP was below the ordered threshold, and another resident received atenolol without documented pulse checks before administration. Staff interviews and MAR review confirmed the medications were given outside or without full monitoring of the physician’s instructions.
Improper medication storage and unattended medications were observed in the facility. Oral meds were stored with external-use products in a med room, expired supplies were found on a treatment cart, a bottle of Colace was left at a resident’s bedside, and an RN and an LVN left prepared meds on top of the med cart during med pass. A medication cup with white paste was also found on a resident’s overbed table without a physician order for skin treatment.
A resident on a regular texture diet was served green beans at lunch instead of the corn on the cob or street corn listed on the menu. The RD stated residents should receive the menu items unless they request a substitution, and there was no documentation that the resident wanted green beans instead of the corn.
Meal Preference Not Honored for a Resident: A resident's tray was served with a turkey sandwich on wheat bread even though the meal ticket specified white bread. CNA and LVN staff identified the mismatch during a dining observation. The RD stated the resident had been cleared by ST for a sandwich and that white bread was the resident's preference as expressed by the resident's son; ST confirmed the resident had preferred white bread for some time.
A resident was served only one 8-ounce carton of non-fat milk at lunch even though the meal ticket listed two cartons under standing orders. The resident stated this happened frequently, and CNA and RD interviews confirmed the resident should have received the full milk order and that meal ticket items should match what residents receive.
Open Dumpster Lid and Improper Trash Storage: The facility failed to keep one of three outside dumpsters fully closed. During observation, a dumpster lid was not fully shut and visible trash bags were on one side of the dumpster. The Maintenance Supervisor confirmed the finding, and the IP stated the trash had not been picked up because of a holiday and the bags were not evenly placed, preventing the lid from closing completely.
Incomplete MAR and POLST documentation was identified for four residents. One resident’s MAR had multiple missing medication, monitoring, and signature entries, including pain, behavior, hydration, and BBW-related documentation, while three residents had POLST Section D left incomplete. Facility staff verified the missing entries during concurrent record review.
Failure to document a required medication storage in-service led to a repeated F761 deficiency. During interview and record review, the Administrator and DSD could not show evidence that the DON in-serviced licensed nursing staff on storing internally administered medications separately from externally administered medications, despite the facility’s prior POC stating that medication storage and labeling education had been provided.
Advance Directive Missing From Medical Record: A resident with no capacity to understand and make decisions had a POLST and care plan noting an advance directive, but the copy was not present in the medical record. During an interview and concurrent chart review, the SSD verified the document was missing from the record.
Failure to provide NOMNC and SNF ABN notices before the last covered Medicare Part A day. A resident’s NOMNC and SNF ABN were not given to the resident or representative before the end of skilled coverage; both forms were signed much later by the representative. Staff stated the NOMNC explains the last covered day and appeal rights, while the SNF ABN explains possible noncoverage, estimated costs, and the resident’s options. The TRC Program Director said the original notices were misplaced and not followed up by social services.
A resident’s Discharge MDS was completed, but the facility did not transmit it within the required timeframe. The MDS Coordinator confirmed the assessment was late, and facility documentation showed it was accepted more than 11 weeks after the required transmission date. The Administrator, nurse consultants, and DSD were informed of the findings.
A resident’s MDS incorrectly showed discharge to an acute care hospital when the resident was actually discharged home, creating inaccurate quality measure data. In another closed record review, a Discharge MDS was completed but not submitted timely, and the facility document showed it was accepted more than 11 weeks after the required transmission date.
Failure to care plan a resident’s refusal of a bedside commode. After a bathroom fall, the IDT added a bedside commode to the care plan, but CNA and RN interviews showed the resident refused to use it and the refusal was not documented or addressed in a separate care plan problem. The DOR confirmed therapy attempted assessment and education, but the resident declined, and the resident stated she had not been made to use the commode and would be willing to try if required.
Medication administration and order route errors were identified when an LVN gave a resident Glycolax via GT without checking for loose stools first, even though the order said to hold the medication if loose stools were present. In another case, a resident with no capacity to make decisions had orders for Creon and Kapspargo listed as PO, while RN staff stated the medications were actually taken via GT and that the orders were incorrect.
Laundry Clean Area Contained Unapproved Items: The facility failed to maintain infection control practices in the laundry room when the clean area contained a pen holder with pens and pencils and a box of tissues on the upper shelf with folded lap robes and blankets. The Laundry Supervisor and Laundry Staff stated those items were not supposed to be there, and the facility’s infection control policy was intended to support a safe, sanitary environment and help prevent transmission of infection.
Rusty Enteral Feeding Pole: A resident receiving enteral feeding was observed with the pump attached to a tube feeding pole that had brownish rust-like areas on the upper portion. RN and IP both verified the pole was rusty, and the Maintenance Supervisor later confirmed the brown areas were rust and stated the issue was missed during routine maintenance rounds.
A resident reported rough handling by a CNA during care, and staff failed to immediately suspend the accused CNA as required by facility policy. The CNA continued working with other residents after the allegation was made. Additionally, the facility did not submit the results of its abuse investigation to the state agency within the required timeframe.
A resident with COPD and anxiety was receiving oxygen at a rate higher than prescribed, contrary to the care plan. The resident's oxygen saturation was below the target level when the oxygen rate was adjusted to the physician's order. This failure to follow the care plan posed a risk of inadequate individualized care.
A facility failed to monitor a resident's fluid intake as per physician's orders, leading to consistent excess fluid consumption. The resident, dependent on hemodialysis, had a prescribed fluid restriction of 1200 ml per day, but records showed intakes exceeding this limit. Interviews with staff confirmed documentation inconsistencies between CNAs and licensed nurses, highlighting a failure in communication and monitoring practices.
The facility failed to administer medications timely for two residents and did not accurately document controlled medications for two others. An LPN did not administer morning medications within the required timeframe, and documentation for controlled substances was incomplete, as confirmed by the DON and staff interviews.
The facility's medication error rate was 8.33%, exceeding the acceptable threshold. A resident received incorrect dosages and unauthorized treatments, including a nicotine patch without a physician's order. Another resident was given a multi-vitamin without minerals, contrary to the prescribed order. These errors were confirmed through observations and interviews with the LVNs involved.
The facility failed to ensure proper medication storage and labeling, with orally and rectally administered medications stored together and a medication drawer found unclean. A nicotine patch was applied to a resident without a physician's order due to missing labels, and there was a discrepancy in hold parameters for a resident's carvedilol medication. These issues could impact residents' well-being and medication effectiveness.
The facility failed to maintain sanitary conditions in the kitchen, risking foodborne illnesses for 125 residents. An ice machine contained an unidentified white powder, raw beef was stored in non-approved grocery bags, and a meal tray drying rack had rust and peeling paint. These issues violated USDA Food Code standards.
The facility failed to maintain infection control practices, as CNAs did not adhere to Enhanced Barrier Precautions (EBP) for two residents. One CNA did not wear a gown while providing incontinence care to a resident, and another CNA failed to don a gown while bathing and changing a resident with a gastrostomy tube. Additionally, there was no receptacle available in a designated EBP room for disposing of used gowns, with the nearest bin located 15 feet away.
A resident with COPD was not provided appropriate respiratory care as the facility failed to follow the physician's order for oxygen administration. The resident was receiving oxygen at a rate of four and a half liters per minute instead of the prescribed two liters per minute, resulting in an oxygen saturation of 86% when adjusted to the correct rate. LVN 8 confirmed the discrepancy and planned to notify the physician.
The facility did not conduct and document a comprehensive facility-wide assessment to determine necessary resources for resident care during routine and emergency situations. This deficiency was identified during a survey when the Administrator admitted that the Facility Assessment had not been completed, and it was only submitted the following day.
A resident with COPD did not have accurate and complete medical records due to missing documentation of pulmonary treatments and medication administration by licensed staff. The facility's policy required documentation by the end of each shift, but records for January showed missing entries for treatments such as Anoro Ellipta inhalation, incentive spirometer use, and chest physiotherapy.
The facility failed to dispose and store trash properly, leading to exposed waste in two out of three dumpsters outside the facility. One dumpster lid was bent, and another was overfilled, violating the US Food Code 2022 and the facility's policy. The DSS confirmed the issue, posing a threat for pest contamination.
Failure to Provide Respiratory Care per Orders
Penalty
Summary
The facility failed to provide necessary respiratory care services for multiple residents, including failure to administer oxygen according to physician orders, failure to maintain proper labeling and dating of respiratory equipment, and failure to keep respiratory supplies stored appropriately when not in use. Surveyors observed several residents receiving oxygen at rates that did not match their orders, including residents receiving higher or lower flow rates than prescribed. In addition, some residents had respiratory equipment that was undated, not bagged, or stored in a bag that was worn, brownish, or labeled for another resident. Resident 24 was observed in bed with oxygen connected, but the nasal cannula prongs were not properly placed in the nostrils. The physician's order required oxygen at 2 LPM continuously to keep oxygen above 92%, but the resident was receiving 3 LPM. Resident 66 was observed receiving 4 LPM of oxygen, although the order was for 3 LPM via nasal cannula with titration up to 4 LPM only to maintain oxygen saturation between 88% and 92%; the record showed oxygen saturations from 93% to 96% and no documented desaturation episodes to support the higher rate. The set-up bag for Resident 66's nasal cannula was dated 1/12/26 and was not changed every seven days. Resident 2 was observed with an oxygen concentrator beside the bed, but the nasal cannula tubing and concentrator were identified as belonging to the roommate, Resident 51, and the set-up bag was dated 1/12/26 rather than changed every seven days. Resident 26 had undated nasal cannula tubing and no set-up bag observed, despite an order for oxygen at 3 LPM continuously and a separate order to change the nasal cannula every 14 days. Resident 6 had nasal cannula tubing dated 1/13/26 on top of an oxygen concentrator, but there was no physician's order for oxygen and no set-up bag for storage when not in use. Additional respiratory care issues were identified with other residents. Resident 1 had an undated nebulizer mask stored in a set-up bag dated 12/3/25, although staff stated the mask and bag should be dated and changed every seven days. Resident 52 had a nebulizer mask dated 1/13/26 stored in an undated set-up bag that was worn and brownish in color, despite an order to change the nebulizer set-up every 14 days and as needed every night shift. Resident 115 was observed receiving oxygen at 3.5 LPM even though the order was for 2 LPM continuously, Resident 9 was observed receiving between 1 and 1.5 LPM despite an order for 2 LPM continuously, Resident 131 had two suction tubing pieces hanging from the suction machine with no date and not stored inside a set-up bag, and Resident 121 was observed receiving oxygen at 2.5 LPM even though the order required 3 LPM continuously for shortness of breath every shift.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
The kitchen failed to meet food safety and sanitation requirements during survey observations and interviews. On an initial tour of the kitchen, opened food items were observed without proper labeling or dating, including a bag of orange beverage connected to the juice dispenser, five juice boxes connected to the juice dispenser, an opened bag of frozen veggie patties in the walk-in freezer, and three opened bags of bread on the bread rack in the dry storage room. The facility’s Director of Dietary Services verified these findings and stated the juice boxes should be labeled with the delivery date and the opened date when first connected to the dispenser, and that food items in the kitchen should be labeled with the opened date when opened. The kitchen also had sanitation issues involving utensils and equipment. During the same tour, a drawer containing clean kitchen utensils was observed with a clear, thick residue at the bottom, and the can opener had a blade with brown residue and a rotating compartment with brownish-orange discoloration. Facility policy stated utensils, counters, shelves, and equipment are to be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas that may affect use or proper cleaning. Additional observations showed damaged or unsanitary food preparation items and storage concerns. A brown cutting board was heavily marred and fuzzy with a brown stain, a green cutting board was heavily marred and fuzzy, and a blue-handle spatula had a melted and discolored handle. A dented can of tomato sauce was observed placed in rotation for use. The resident food refrigerator in the therapy room had black particles on the shelf and brownish staining on the drawer handles, and a paper towel used to wipe the shelf picked up brownish-black residue. The facility also used chlorine test paper for the low-temperature dishwasher that had expired in 8/2025, and during pureed food preparation a stainless-steel blender and blade were observed wet while the cook was preparing to add chicken to the blender.
Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure seven sampled residents were free from unnecessary psychotropic medication use and failed to document required monitoring and nonpharmacological interventions associated with those medications. The report states that the facility did not ensure orthostatic blood pressure monitoring for residents receiving antipsychotic medications, did not consistently document behavior monitoring tied to the stated indications for psychotropic drugs, and did not document nonpharmacological interventions or their effectiveness when behaviors were observed. For one resident with diagnoses including anxiety disorder and bipolar disorder, olanzapine was ordered for mood swings, and hydroxyzine and Ativan were ordered for anxiety manifested by uncontrolled crying causing physical exhaustion. The record showed frequent episodes of mood swings and crying, but there was no documentation of orthostatic hypotension monitoring for olanzapine and no documentation of nonpharmacological interventions implemented for the observed behaviors related to olanzapine, hydroxyzine, or Ativan. Staff interviews confirmed the absence of those documented interventions and monitoring. For another resident with moderately impaired cognition and diagnoses including non-Alzheimer's dementia and major depressive disorder, aripiprazole was ordered for schizophrenia manifested by resistive to care, Cymbalta was ordered for schizoaffective depressive type manifested by verbally feeling depressed, and temazepam was ordered for insomnia. The record did not show orthostatic hypotension monitoring for aripiprazole, and staff confirmed the resident did not have the diagnoses listed for aripiprazole and Cymbalta. The record also showed temazepam administration on multiple dates, but monitoring of hours of sleep was only documented for an earlier period and not after that point. Additional residents had similar documentation problems. One resident receiving Cymbalta had pain used as the behavior manifestation, but the record did not show physician justification for using pain in that way and the monthly behavior summary did not match the pain episodes documented in the MAR. Another resident receiving Remeron had meal intake documented in ranges that did not allow staff to identify when intake was less than 50%, and the monthly behavior summary showed zero episodes despite documented poor intake. Other residents receiving lorazepam, Remeron, quetiapine, and sertraline also lacked documentation of required nonpharmacological interventions, side-effect monitoring, orthostatic blood pressure monitoring, or accurate behavior summaries as described in the report.
Failure to Respond to Low Blood Pressure
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided for Resident 31 when the resident had a blood pressure reading of 76/51 mmHg. Resident 31 was admitted to the facility with no capacity to understand and make decisions, and the medical record showed blood pressure readings of 76/51 mmHg at 1800 hours, 90/51 mmHg at 1818 hours, and 153/74 mmHg at 1935 hours on 12/28/25. The record did not show an intervention was implemented for the low blood pressure reading between 1800 and 1818 hours. Further review showed that at 0005 hours on 12/29/25, Resident 31 was lethargic, slow to respond to verbal and tactile stimuli, and had a blood pressure reading of 68/80 mmHg. At 0020 hours, RN 5 called 911, and at 0037 hours the paramedics transported Resident 31 to the acute care hospital. At 0500 hours, RN 5 contacted the hospital and learned Resident 31 was admitted with a diagnosis of septic shock. RN 2 verified the findings and stated that when residents had low blood pressure readings, the expectation was to inform the clinician for further evaluation at the acute care hospital and to implement interventions such as elevating the resident's legs and/or starting intravenous fluids. RN 2 stated she did not find documentation showing an intervention or notification about the low blood pressure was implemented.
Failure to Reposition Resident With Pressure Injury
Penalty
Summary
The facility failed to ensure necessary care and services were provided to prevent the development of pressure injuries for one sampled resident, Resident 135. Resident 135 was admitted with the capacity to understand and make decisions and had blanchable redness on the coccyx on admission. Her care plan identified risk for skin breakdown related to decreased mobility/immobility and incontinence and included repositioning at least every two hours and as needed. Subsequent skin assessments showed worsening condition at the sacrum and coccyx, including non-blanchable redness, superficial skin breakdown with reddened fragile tissue and excoriation, and later an unstageable pressure injury to the coccyx with 100% slough. The documentation survey reports for December 2025 and January 2026 showed multiple instances when Resident 135 was not turned in bed every two hours, both before and after the pressure injury was identified. During interviews, Resident 135 stated she developed the pressure injury while in the facility and said staff were not turning her every two hours before or after the injury was present. She stated she could turn herself but it was difficult because of the low air loss mattress and that staff did not assist or remind her to turn every two hours. The LVN and DON acknowledged the resident’s risk factors and verified that the expected interventions included turning and repositioning every two hours, and that staff were expected to follow the care plan.
Failure to Use Ordered Bilateral Floor Mats for Two Residents
Penalty
Summary
The facility failed to ensure residents remained free from accident hazards when it did not implement bilateral floor mats as ordered and care planned for two sampled residents, Residents 14 and 22. Facility policy for falls and fall risk stated staff, with input from the attending physician, would implement a resident-centered fall prevention plan to reduce each resident’s specific fall risk factors. Resident 14 had a care plan problem dated 8/19/24 for falls and injuries related to getting up without asking for assistance, confusion, impaired mobility, and weakness, with interventions for floor pads on both sides of the bed for safety. Resident 14’s H&P dated 3/30/25 stated the resident had no capacity to understand and make decisions. On 1/22/26, Resident 14 was observed in bed with only one floor pad on the left side, while CNA 8 stated the resident only used one floor pad and attempted to pull up on the right side of the bed where no pad was present. RN 2 later verified there should always be two floor pads positioned on each side of the bed when Resident 14 was lying in bed. Resident 22 had a care plan revised 11/12/25 for fall risk/further falls due to poor or no safety awareness, impaired vision/hearing, unsteady gait/balance problems, and wandering, with interventions for bilateral floor mats. Resident 22’s H&P dated 11/5/25 stated the resident had the capacity to understand and make decisions. On 1/22/26, Resident 22 was observed in bed with one of the bilateral floor pads folded up and leaning against the foot of the bed. CNA 3 confirmed the pad was folded up while the resident was lying in bed and stated sometimes both floor pads were used and other times only one was used. CNA 3 also verified the resident had a history of falls and was considered a fall risk. RN 2 confirmed Resident 22 was a fall risk, had a last fall episode on 12/20/25, and had a care plan intervention for bilateral floor pads when in bed, stating both pads should be on each side of the bed.
Pain Medications Given Without Proper Assessment and Non-Pharmacologic Documentation
Penalty
Summary
The facility failed to provide appropriate pain management for three residents who were reviewed for pain control. The facility’s pain management policy required a pain assessment, evaluation and documentation of non-pharmacologic interventions, administration of pain medications as ordered, and reassessment of pain 30 to 60 minutes after medication administration. The survey found that these steps were not consistently followed for Residents 3, 8, and 10. For Resident 8, who had no capacity to understand and make decisions and was being treated for pain related to a right femoral fracture status post ORIF, the record showed PRN acetaminophen was ordered for mild to moderate pain and PRN hydrocodone-acetaminophen was ordered for severe pain. The MAR showed hydrocodone-acetaminophen was given for a pain level of 6 on multiple occasions, and staff confirmed that acetaminophen should have been given instead based on the resident’s pain level. The record also showed multiple administrations of hydrocodone-acetaminophen for pain levels of 7 or 8, but the medical record did not show documentation of non-pharmacological interventions attempted before those doses. For Resident 10, who was cognitively intact and had a care plan for pain, the physician ordered non-pharmacological interventions to be documented before PRN pain medication, along with Tylenol for mild pain and hydrocodone-acetaminophen for severe pain. The MAR showed hydrocodone-acetaminophen was administered on several occasions when the documented pain level was below the ordered severe-pain range of 7 to 10, including pain levels of 3, 5, and 6. The record also showed Tylenol was given for pain levels of 3 and 4, and hydrocodone-acetaminophen was given for pain level 7 on multiple other occasions, but the medical record did not show documentation of non-pharmacological interventions attempted before these administrations. For Resident 3, who had no capacity to understand and make decisions and had a care plan addressing pain with non-pharmacological measures such as relaxation, diversion, music therapy, positioning, turning, heat or cold, massage, and back rub, the record showed scheduled Norco and a lidocaine patch were administered repeatedly. The MAR documented pain level as zero for many of the Norco administrations, yet the medical record did not show documentation of non-pharmacological interventions attempted before the Norco or lidocaine patch were given. Staff stated that non-pharmacological interventions should be implemented and documented before pain medication, and that pain medication should not have been given when the pain level was zero.
Inaccurate Fluid Intake Monitoring for Resident on Hemodialysis
Penalty
Summary
The facility failed to accurately monitor fluid intake and output for a resident with ESRD who required hemodialysis and had physician orders for hemodialysis on Tuesdays, Thursdays, and Saturdays, intake and output every shift, and a 1200 ml/day fluid restriction. The order specified that the kitchen would provide 840 ml total daily and nursing would provide 360 ml total daily. Review of the resident’s records showed repeated days in December 2025 and January 2026 when the resident exceeded the prescribed dietary fluid intake documented by the dietary survey report. The resident’s MAR also showed multiple days when the total fluid intake exceeded both the nursing allotment and the 1200 ml daily limit, including totals documented as high as 2620 ml. The MAR entries included TI, identified by staff as total intake from nursing and dietary sources across shifts, but the documented TI amounts did not match the actual totals from the nursing and dietary documentation. On 1/23/26, CNA 2 stated the resident had 240 ml at breakfast and 120 ml at lunch, and LVN 2 stated the resident had 180 ml from the morning medication pass, for a total of 420 ml in the AM shift. RN 3 confirmed the resident’s AM shift intake totaled 420 ml but documented 400 ml instead, stating she was in a rush. RN 1 later verified that the MAR’s TI entries were inaccurate because they did not match the total intake from nursing and dietary departments, and also verified that the resident exceeded the prescribed dietary fluid intake and the total 1200 ml daily fluid restriction as documented in the records.
Failure to Follow Hold Parameters for Blood Pressure Medications
Penalty
Summary
The facility failed to ensure two sampled residents were free from unnecessary medications by not following ordered parameters for blood pressure medications. Resident 10, who was cognitively intact and had an order for carvedilol 3.125 mg twice daily with instructions to hold the medication if systolic blood pressure was less than 110 mmHg or heart rate was less than 60 beats per minute, received carvedilol on multiple occasions when the documented blood pressure was below the ordered hold parameter. The MAR showed administrations on 1/1, 1/7, 1/10, 1/14, and 1/18 when systolic blood pressure readings ranged from 93 to 109 mmHg. During interview and record review, the LVN verified the findings and stated the medication should not have been administered as ordered. Resident 6 had an order for atenolol 50 mg every morning with instructions to hold if systolic blood pressure was less than 110 mmHg or pulse was less than 60 beats per minute. The MAR showed the medication was administered from 1/1 through 1/22/26, and while blood pressure readings were documented, there was no documentation that the resident’s pulse was monitored before atenolol was given. RN 1 reviewed the record and verified that the licensed nurses should have monitored both blood pressure and pulse before administering the medication.
Improper medication storage and unattended medications
Penalty
Summary
The facility failed to keep oral medications separated from external-use medications in Medication Room [ROOM NUMBER]. During inspection, omeprazole tablets were stored with bisacodyl suppositories and earwax softener drops, and vitamin B complex and probiotic capsules were stored with fluticasone propionate nasal spray. During interview, LVN 1 stated that external and internal medications needed to be stored separately to prevent accidental mix up of the medications, and verified the findings. The facility also failed to remove expired supplies from Treatment Cart A. The cart contained alcohol wipes with an expiration date of 7/2025 and five packs of DermaCol/Ag Collagen Matrix with an expired date. LVN 1 stated expired biologicals or supplies should be removed from the treatment cart and noted that expired supplies such as alcohol wipes or dressing may not be potent and would not have full effectiveness. The DON was informed of these findings and acknowledged them. The facility further failed to prevent medications from being left at bedside or unattended during medication administration. A bottle of Colace was observed on Resident 148's nightstand, and the resident stated she sometimes self-administered it but was unsure how long it had been there. RN 4 verified the bottle should have been stored securely. During medication pass observations, RN 4 left prepared medications on top of the medication cart while entering Resident 88's room, and a nebulizer unit dose was also observed unattended on a medication cart; LVN 7 similarly left a nebulizer unit dose on top of the cart while entering Resident 2's room. In addition, a medication cup containing white paste was observed on Resident 1's overbed table, and RN 1 verified there was no physician's order for any skin treatment for Resident 1.
Menu Item Not Followed for Resident Meal
Penalty
Summary
The facility failed to ensure the menu for the regular diet was followed for one of 85 residents who received food from the kitchen. On 1/20/26, the facility’s Week at a Glance menu listed BBQ pork loin, Spanish rice, corn on the cob, bread or roll with margarine, apple pie, street corn, and a choice of beverage for lunch, and the Order Listing Report showed 85 residents had regular diets and received food from the kitchen. Resident 82 had a physician’s order for a fortified IDDSI regular level 7 texture diet with thin liquids and had been admitted to the facility with capacity to understand and make decisions. During the dining observation, Resident 82 was served Spanish rice, BBQ pork loin, and steamed green beans instead of the corn on the cob or street corn listed on the menu. Resident 82 stated he did not ask for green beans instead of the corn that was on the menu. The RD stated residents should be served what was listed on the menu unless requested by the resident, and that the meal ticket should match what the resident would receive, including substitutions or preferences. The RD reviewed Resident 82’s meal ticket and stated there was no documentation that Resident 82 wanted green beans instead of the corn on the cob.
Meal Preference Not Honored for Resident
Penalty
Summary
The facility failed to ensure that Resident 3 received food that matched the resident's documented preference for white bread. During a dining observation, Resident 3's tray contained a turkey sandwich on wheat bread, even though the meal ticket specified a finely chopped turkey sandwich on white bread. CNA 10 noticed the discrepancy while attempting to feed the resident and reviewed the meal ticket, confirming that white bread was ordered. LVN 1 also observed the tray and stated that the wheat bread had not been seen when the tray was checked. Resident 3 was admitted to the facility and had no capacity to understand and make decisions, according to the H&P. The physician's order showed a regular diet with minced and moist texture, and the RD stated that the resident had been cleared by ST to have a sandwich as listed on the meal ticket. The RD further stated that white bread was the resident's preference as expressed by the resident's son, and the ST confirmed that Resident 3 had preferred white bread for some time. The facility stated that the tray checks in the kitchen and dining room missed the wheat bread served on the resident's tray.
Meal Ticket Not Followed for Resident’s Milk Order
Penalty
Summary
The facility failed to accommodate a resident’s drink preference and meal ticket order when Resident 111 was served only one 8-ounce carton of non-fat milk with lunch instead of the two cartons listed under the resident’s standing orders. During a lunch observation in the dining room, Resident 111 was seen eating with one carton of milk, and the meal ticket was reviewed and confirmed to specify two 8-ounce cartons of non-fat milk for the lunch meal. During interview, Resident 111 stated this happened frequently and that he often received only one carton of milk when he should have received two. CNA 9 verified that the resident should be served what was on the meal ticket and then asked the resident if he wanted his second carton of milk, which the resident accepted. The RD also verified that the meal ticket items should match what residents receive, including substitutions and preferences, and stated Resident 111 should have been served two cartons of milk for lunch.
Open Dumpster Lid and Improper Trash Storage
Penalty
Summary
The facility failed to ensure garbage and refuse were properly stored for one of three dumpsters when one dumpster lid was not fully closed and visible bags of trash were present on the left side of the dumpster. During observation with the Maintenance Supervisor, the open lid was confirmed, and the facility’s policy and the USDA Food Code required outside garbage receptacles to be kept covered with tight-fitting lids or covers. The Maintenance Supervisor stated that housekeeping, dietary, and maintenance staff had been educated to keep dumpster lids closed. During interview, the IP stated he had been informed of the open dumpster lid, explained that garbage had not been picked up because of a holiday, and stated the dumpster was not overflowing but the trash bags were not evenly placed, which caused the lid not to fully close.
Incomplete MAR and POLST Documentation
Penalty
Summary
The facility failed to ensure medical records were accurately completed for four of 27 final residents, including Resident 3, Resident 5, Resident 8, and Resident 135. The cited concern involved incomplete documentation in the MAR and POLST forms, with the report stating that the incomplete records created a potential risk for residents not to be provided with care and treatment because the medical record information was incomplete. For Resident 3, review of the MAR showed multiple missing entries on the specified date, including an uncompleted and unsigned Tylenol administration entry, missing behavior monitoring documentation for anxiety, sertraline, Seroquel, and use of Seroquel, missing pain assessment documentation, missing monitoring entries for several black box warning-related medications, missing sepsis monitoring data, missing hydration documentation, and missing monitoring for central nervous system depression related to methocarbamol and Norco. During concurrent record review, LVN 6 and LVN 2 verified the missing entries, and LVN 2 stated that documentation should be completed right after medications were administered. The MRD also verified the missing MAR entries and stated the MARs were audited daily. For Residents 5, 135, and 8, review of the POLST forms showed Section D for the advance directive was not completed. Resident 5’s H&P showed he had capacity to make his own decisions, and his care conference documentation showed he had issued an advance directive about his care and treatment. Resident 135’s H&P showed capacity to understand and make decisions, while Resident 8’s H&P showed no capacity to understand and make decisions. The SSD verified the incomplete POLST findings for all three residents, and for Resident 5 stated Section D should have been completed upon admission or updated as needed.
Failure to Document Medication Storage In-Service
Penalty
Summary
The facility failed to implement its QAPI plan of action related to a repeated deficiency cited at F761 from the prior recertification survey completed on 1/9/25. During an interview and concurrent document review on 1/26/26 at 1443 hours with the Administrator and DSD, surveyors found no documentation showing that the DON had provided an in-service to licensed nursing staff on medication storage and labeling, specifically on storing internally administered medications separately from externally administered medications. The review of the facility’s POC submitted to CDPH, L&C Program showed the DON had in-serviced licensed nursing staff on 1/7/25 regarding medication storage and labeling, but the Administrator and DSD were unable to produce documented evidence that this in-service included the required separation of internally administered medications from externally administered medications.
Advance Directive Missing From Medical Record
Penalty
Summary
The facility failed to ensure that the advance directive for one resident was obtained and maintained in the medical record. Review of the facility policy on Advance Directives showed that if a resident or the resident’s representative has executed an advance directive, copies are to be obtained and maintained in the same section of the medical record and readily retrievable by staff. Resident 3 was admitted to the facility and had an H&P examination dated 3/12/25 documenting no capacity to understand and make decisions. The resident’s POLST dated 3/12/25 showed the resident had an advance directive, and the IDT Care Conference and Care Plan Review dated 12/18/25 also showed the resident had an advance directive. Despite these references in the record, further review failed to show a copy of Resident 3’s advance directive was actually obtained and maintained in the medical record. During an interview and concurrent medical record review on 1/21/26 at 0805 hours, the SSD verified that the medical record did not contain the copy of the resident’s advance directive. The SSD stated she would speak to the resident’s representative to obtain the copy of the resident’s advance directive.
Failure to Provide Medicare Non-Coverage and Liability Notices
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, CMS-10055) to Resident 100 before the resident’s last covered Medicare Part A day of 10/8/25. Review of the medical record showed the NOMNC stated the resident’s Medicare coverage for current skilled Part A services would end on 10/8/25, and the SNF ABN stated that beginning on 10/8/25 the resident may have to pay out of pocket if no other insurance covered the cost. Both forms were signed by the resident’s representative on 1/26/26, and the record did not show that the resident or representative had been provided the forms before the last covered day. During interview and concurrent record review on 1/26/26, the SSD explained that the NOMNC is used to notify residents of their last covered day of Medicare Part A, their right to appeal, and how to appeal, while the SNF ABN explains what care may not be covered, why Medicare may not pay, the estimated cost, and the resident’s options regarding receiving or declining the care. The TRC Program Director stated the resident’s Medicare Part A skilled services episode began on 9/23/25 and that the last covered day was 10/8/25. The TRC Program Director also stated the NOMNC and SNF ABN should be given at least two days before the last covered date, and said the original notice for both forms was misplaced and was not followed up by the TRC social services department.
Late Transmission of Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit Resident 116’s Discharge MDS assessment within 14 days of the completion date. Resident 116 was admitted to the facility and later discharged on 10/11/25. Review of the Discharge MDS assessment showed that RN 1 signed the assessment as complete on 10/20/25, but the submission date was not listed in the record. During a closed medical record review and interview with the MDS Coordinator on 1/21/26, the MDS Coordinator stated the Discharge MDS was completed timely but then verified that it was not submitted timely and was late. Facility documentation showed the Discharge MDS assessment was accepted on 1/21/26, more than 11 weeks past the required transmission date of 11/3/25. On 1/26/26, the Administrator, Nurse Consultants 1 and 2, and the DSD were informed of and acknowledged the findings.
Inaccurate and Late MDS Discharge Assessments
Penalty
Summary
The facility failed to complete an MDS assessment accurately for one of three sampled residents reviewed for closed records. Resident 142's MDS assessment indicated the resident was discharged to an acute care hospital when the resident was actually discharged home, resulting in inaccurate resident data used for quality measure purposes. In a separate closed record review for Resident 116, the Discharge MDS assessment was signed as complete by RN 1 on 10/20/25, but the submission date was not listed. During interview and record review with the MDS Coordinator, the assessment was confirmed to have been completed timely but not submitted timely. The facility document showed the Discharge MDS was accepted on 1/21/26, more than 11 weeks after the required transmission date of 11/3/25.
Failure to Care Plan Resident’s Refusal of Bedside Commode
Penalty
Summary
The facility failed to develop a comprehensive resident-centered plan of care for Resident 22 by not creating a care plan problem to address the resident’s refusal to use the bedside commode. Resident 22 was admitted to the facility and had an H&P documenting capacity to understand and make decisions. The resident’s care plan had been revised to address a fall in the bathroom and included the use of a bedside commode as an intervention. During observation and interviews, CNA 3 stated Resident 22 did not use the bedside commode because the resident refused to use it, and the licensed nurse was aware of the refusal. RN 2 confirmed the fall, the IDT recommendation for a bedside commode, and that the recommendation was included in the care plan, but also stated the resident’s refusal should have been documented and a care plan should have been developed for the refusal. The DOR stated therapy attempted to assess and educate Resident 22 on the bedside commode, but the resident refused, and the facility did not document the assessment, education, or refusal. Resident 22 stated she had not been made to use the bedside commode and would be willing to try if required. RN 2 later stated there should have been a care plan with interventions addressing the refusal and that an IDT meeting should have been completed after the refusal to prevent another fall.
Medication Administration and Order Route Errors
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure appropriate medication administration. During a medication administration observation for Resident 131, LVN 6 prepared Glycolax oral powder mixed with water and administered it via GT, but did not check whether the resident had loose stools before giving the medication. The resident’s physician order for Glycolax, dated 2/5/23, directed that the medication be given via GT in the morning for bowel management, mixed with eight ounces of water, and held if the resident had loose stools. During the concurrent interview and record review, LVN 6 acknowledged that she did not verify whether the resident had loose stools and stated she should have checked the CNA documentation under Tasks. For Resident 121, the medical record showed an H&P dated 5/10/25 stating the resident had no capacity to understand and make decisions. The order summary included a 9/7/23 order stating capsules could be opened and granules administered via feeding tube or added to applesauce or juice, a 2/9/24 order for Creon oral capsule delayed release to be given by mouth every eight hours, and a 2/24/25 order for Kapspargo oral capsule extended release to be given by mouth daily for hypertension. During interview and record review, RN 4 stated Resident 121 took the Creon and Kapspargo medications by mouth and verified that the physician’s orders were incorrect, stating they should be changed to GT. The Administrator, DSD, and Nurse Consultant 1 acknowledged the findings.
Laundry Clean Area Contained Unapproved Items
Penalty
Summary
The facility failed to maintain its infection prevention and control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infection. During observation of the laundry room with the Laundry Supervisor and Laundry Staff, the clean area of the laundry room had a pen holder with pens and pencils and a box of tissue on the upper shelf, along with folded lap robes and blankets. The Laundry Supervisor and Laundry Staff stated that the pen holders and box of tissues were not supposed to be there. The facility's infection control policies and practices, dated January 2023, stated they were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage the transmission of disease and infection.
Rusty Enteral Feeding Pole
Penalty
Summary
The facility failed to maintain essential equipment in proper working and sanitary condition when Resident 131's tube feeding pole was observed with brownish rust-like areas on the upper portion of the pole. During the initial tour, the resident was in bed with enteral feeding in progress, and the enteral feeding pump was attached to the pole that showed the rust-like areas. RN 4 later verified that the enteral feeding pole had brownish rust-like areas and stated that the pole was rusty. The Infection Preventionist also verified the rust-like areas and stated the tube feeding pole was rusty. The Maintenance Supervisor was shown the pole and identified the brown-like areas as rust, and later stated the issue was missed when maintenance staff made rounds and reviewed reports from the nurses' stations.
Failure to Follow Abuse Investigation Protocol and Timely Reporting
Penalty
Summary
The facility failed to follow its abuse investigation protocol after a resident reported rough handling by a CNA during care. The resident, who was cognitively intact and able to make his own decisions, reported to staff that the CNA did not stop providing care when asked multiple times. Both an LVN and an RN observed or were informed of the incident, and the RN acknowledged that the situation constituted an allegation of abuse. Despite facility policy requiring immediate suspension of any employee accused of abuse pending investigation, the CNA continued to work with other residents for the remainder of the shift. The RN did not report the incident to the Administrator immediately, nor was the CNA suspended as required by policy. Additionally, after the facility completed its investigation and determined the allegation was unsubstantiated, the Administrator failed to submit the results of the investigation to the California Department of Public Health, Licensing & Certification Program, Orange District Office within five working days, as required by both facility policy and regulation. The Administrator acknowledged that this reporting requirement was missed. These failures were confirmed through interviews with staff and review of facility policies and documentation.
Failure to Implement Comprehensive Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident identified as being at risk for respiratory distress. The resident, who has a history of COPD and anxiety, was observed receiving oxygen at a rate of four and a half liters per minute, contrary to the physician's order of two liters per minute. This discrepancy was noted during an observation and interview with an LVN, who subsequently adjusted the oxygen flow to the correct rate as per the physician's order. Upon adjusting the oxygen flow to the prescribed rate, the resident's oxygen saturation level was measured at 86%, which is below the care plan goal of maintaining oxygen saturation at 92% or greater. The facility's policy and procedure for oxygen administration, revised in June 2023, requires that the resident's care plan identify interventions for oxygen therapy based on the resident's assessment and orders. The failure to adhere to the prescribed oxygen rate posed a risk of not providing appropriate individualized care to the resident.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to adequately monitor and manage the fluid intake of Resident 106, who was dependent on hemodialysis due to end-stage renal disease. The physician's orders specified a fluid restriction of 1200 ml per 24 hours, with specific allocations for meals and nursing shifts. However, the facility's records showed that the resident's fluid intake consistently exceeded the prescribed limits, with daily totals surpassing the allowed amounts from meals alone. This discrepancy was noted in the Documentation Survey Report for CNAs, which recorded fluid intakes from meals that were higher than the allotted 720 ml, and the Medication Administration Record (MAR), which showed total daily intakes that often exceeded the prescribed 1200 ml. Interviews with the LVN and the Director of Nursing (DON) confirmed these findings and revealed inconsistencies in the documentation of fluid intake by CNAs and licensed nurses. The CNAs were responsible for documenting fluid intake from meals, while licensed nurses were expected to collaborate with CNAs to calculate the total intake, including fluids provided by nursing. The DON acknowledged the inconsistency between the MAR and the Documentation Survey Report, indicating a failure in communication and documentation practices that led to the resident's fluid intake not being properly monitored and managed as per the physician's orders.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide timely administration of medications for two residents, as observed during a survey. LVN 6 was responsible for administering medications to residents, but Residents 63 and 77 did not receive their scheduled morning medications at 0900 hours within the required 60-minute window. This delay was confirmed during an interview with LVN 6, who acknowledged the failure to adhere to the facility's policy on medication administration timing. Additionally, the facility did not maintain accurate documentation for controlled medications administered to two other residents. For Resident 85, the administration of oxycodone-acetaminophen was not documented in the Medication Administration Record (MAR) on a specific date, despite being dispensed and signed out. This discrepancy was verified by LVN 9 and the Director of Nursing (DON), who confirmed the need for proper documentation in the MAR. Similarly, for Resident 118, the administration of buprenorphine was not recorded in the Narcotic and Hypnotic Record on a particular date. LVN 3, who was responsible for administering the medication, admitted to failing to document the administration immediately after giving the medication. The DON and Administrator were informed of these findings, which highlighted lapses in the facility's medication administration and documentation processes.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8.33%. This deficiency was identified through observations, interviews, and medical record reviews. Specifically, Resident 4 received incorrect medication dosages and unauthorized treatments. The Licensed Vocational Nurse (LVN) administered 1000 micrograms of vitamin B12 instead of the prescribed 5000 micrograms and applied a nicotine transdermal patch without a physician's order. These actions were confirmed during an interview with LVN 10, who acknowledged the discrepancies between the administered medications and the physician's orders. Additionally, Resident 63 was administered a multi-vitamin tablet without minerals, contrary to the physician's order for a multi-vitamin/minerals tablet. This error was observed during a medication administration session with LVN 6, who verified the mistake upon reviewing the physician's orders. These medication administration errors have the potential to negatively impact the residents' health, as they deviate from the prescribed treatment plans.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, as evidenced by several deficiencies observed during a survey. In Medication Cart 5, orally administered medications were stored together with rectally administered medications, contrary to the facility's policy that requires these to be stored separately. Additionally, the medication drawer was found to be unclean, with dried white residue present. These findings were verified by the Director of Nursing (DON) during the inspection. Furthermore, a package containing nicotine 21 mg transdermal patches was not labeled with essential information such as the resident's name, prescribing physician's name, prescription number, or prescribed dose. This led to a Licensed Vocational Nurse (LVN) applying a nicotine patch to a resident without a physician's order. In another instance, there was a discrepancy between the physician's order and the medication packaging for a resident's carvedilol medication, leading to confusion about the correct hold parameters based on the resident's systolic blood pressure. These failures had the potential to negatively impact the residents' well-being and the stability and effectiveness of the medications.
Sanitation Deficiencies in Kitchen Pose Risk for Foodborne Illness
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, posing a risk for foodborne illnesses among the 125 residents who received food prepared there. During an inspection, an ice machine was found with an unknown white powder substance floating in the water trough, which the maintenance staff initially identified as hard water deposits and later as chlorine, but ultimately could not confirm its identity. This substance had been accumulating since the last cleaning on December 27, 2024, indicating a failure to properly maintain the ice machine according to the facility's policy and procedures. Additionally, raw beef chuck was improperly stored in plastic grocery bags within Freezer 1, which were not approved for food storage, as confirmed by the Dietary Services Supervisor (DSS). Furthermore, a meal tray drying rack was observed with a brown residue resembling rust and peeling paint, which was verified by the DSS. These unsanitary conditions in food storage and equipment cleanliness were in violation of the USDA Food Code 2022, which requires that equipment, food-contact surfaces, and utensils be clean to sight and touch.
Infection Control Deficiencies in PPE Usage and Disposal
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations and interviews. CNA 1 did not adhere to Enhanced Barrier Precautions (EBP) when providing incontinence care to Resident 58, as she wore gloves but failed to don a gown, despite the EBP sign indicating the requirement for both gloves and a gown for high-contact resident care activities. CNA 1 acknowledged the oversight during an interview, stating it was an accident. The Infection Preventionist (IP) confirmed that ongoing education on EBP was provided to staff, and acknowledged the finding. Additionally, CNA 6 did not follow the required EBP when providing care to Resident 50, who had a physician's order for enhanced barrier precautions due to a gastrostomy tube (GT). CNA 6 was observed bathing and changing Resident 50's adult brief while only wearing gloves, failing to don a gown as required. The IP verified that staff members were required to wear both gloves and a gown for such care. Furthermore, there was no receptacle readily available in Room A, designated for enhanced barrier precautions, to dispose of used gowns. LVN 1 indicated that the used gowns would be placed in a bin located approximately 15 feet away from the room.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident diagnosed with COPD, as evidenced by not adhering to the physician's order for oxygen administration. The physician's order specified that the resident should receive supplemental oxygen at a rate of two liters per minute to maintain an oxygen saturation level of 92% or greater. However, during an observation, the resident was found to be receiving oxygen at a rate of four and a half liters per minute, which was not in accordance with the physician's order. Upon further investigation, it was confirmed by LVN 8 that the resident was indeed receiving oxygen at the incorrect rate. When the oxygen rate was adjusted to the prescribed two liters per minute, the resident's oxygen saturation dropped to 86%, indicating a change in condition. LVN 8 acknowledged the discrepancy and stated that the physician would be notified of the resident's condition. This failure to follow the physician's order for oxygen administration had the potential to result in negative health outcomes for the resident.
Failure to Conduct and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified during a survey when the surveyors requested the Facility Assessment during an entrance conference with the Administrator and the Director of Nursing (DON). The Administrator admitted that the Facility Assessment had not been completed at the time of the request. The assessment was only submitted to the survey team the following day, indicating a delay in compliance with regulatory requirements.
Incomplete Documentation of Pulmonary Treatments for a Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding the documentation of pulmonary administration as ordered by the physician. The resident, who was admitted to the facility with a history of COPD, had several physician's orders related to pulmonary treatments and medication administration. These included the use of Anoro Ellipta inhalation, incentive spirometer treatments, chest physiotherapy via Acapella, and oxygen administration. However, the medical records for January 2025 showed missing documentation by licensed nurses for these treatments and medications on specific dates. During interviews and medical record reviews, it was confirmed that the licensed staff did not document the administration of the prescribed treatments and medications for the resident. The Director of Nursing (DON) acknowledged that the facility's policy required documentation to be completed by the end of each shift. The lack of documentation for the resident's pulmonary treatments and medication administration resulted in incomplete and inaccurate medical records, which could potentially impact the resident's healthcare needs.
Improper Trash Disposal and Storage
Penalty
Summary
The facility failed to dispose and store trash in a sanitary manner, which posed a threat for pest contamination. During an observation of trash disposal, two out of three dumpsters located outside the facility were found with lids not completely closed. One dumpster lid was bent, and the other dumpster was overfilled with trash, leading to exposed waste. The Director of Support Services (DSS) confirmed that the trash was exposed and the lids of the two dumpsters were not fully closed. This observation was in violation of the US Food Code 2022, Section 5-501.113, which requires receptacle units for refuse to be kept covered with tight-fitting lids after they are filled. Additionally, the facility's policy and procedure for disposing of garbage and refuse, revised on 12/19/22, mandates that refuse containers and dumpsters outside the facility should have tightly fitting lids, doors, or covers.
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Illustrative
What surveyors actually found near you
We read the 5,346 citations issued within 25 miles in the last 12 months — including the 22 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anaheim Healthcare Center, Llc | 0.1 mi | ★★★★★ | 5 | 0 |
| Anaheim Crest Nursing Center | 0.6 mi | ★★★★★ | 3 | 0 |
| West Anaheim Medical Center D/p Snf | 0.6 mi | ★★★★★ | 16 | 0 |
| Buena Park Nursing Center | 1.2 mi | ★★★★★ | 48 | 0 |
| Anaheim Terrace Care Center | 1.2 mi | ★★★★★ | 2 | 0 |
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