Average — CMS composite of the measures below.
A standard survey is most likely before 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 Bonita Hills Post Acute during CMS and state inspections, most recent first.
The facility failed to follow its own policies for documenting and accounting for a resident's personal belongings at discharge. A cognitively intact resident’s clothing and possessions form included an itemized list on admission but the discharge section was left incomplete, marked only with "discharge AMA" and no detailed inventory. During interviews, a CNA and an RN confirmed that staff should have counted, sorted, and documented the resident’s belongings, placed them in a labeled bag, and routed them appropriately, but this was not done. The DON acknowledged that whoever packed the belongings should have specified the items on the form to maintain an accurate account of the resident’s possessions.
A cognitively intact resident arranged a podiatry appointment and left the facility by bus for that visit, but staff failed to obtain and document a physician’s order for the appointment in the EMR. Facility policies required that social services assist with transportation and that licensed staff document all services and appointments in the medical record. An RN, the Social Services Assistant, and the DON all confirmed that no physician order existed for the podiatry appointment, despite knowledge of the scheduled visit and usual practice that such appointments be entered as physician orders so all departments could coordinate care and transportation.
A resident experienced a change in urine color from yellow to dark amber, which was documented by an LVN but not reported to the physician as required by facility policy. Interviews with the LVN, PA, and DON confirmed that the physician was not notified, and there was no documentation of such notification in the medical record.
A licensed nurse administered Tylenol to a resident for a temperature of 99°F, despite a physician's order specifying the medication should only be given if the temperature exceeded 100.5°F. The QA Nurse and DON confirmed that the medication was given outside the ordered parameters.
Kitchen food safety and sanitation deficiencies were identified when pasteurized eggs were not available for a resident who requested over easy fried eggs each morning, despite staff using shell eggs they believed were pasteurized. Surveyors also observed four fry pans with greasy residue and food debris, three steamtable pans stacked wet, a food prep sink without an air gap, and four cereal bins past their use-by date in a hot dry storeroom.
A resident’s call light was not functioning properly, and staff knew about the problem for about two weeks. The resident, who had a fall-risk care plan and needed q2h repositioning, reported that she was given a call bell instead, but it did not work well when her bedroom door was kept closed per her preference. When tested, the alarm sounded at the nurse’s station without identifying the room, and staff could not tell which resident needed help.
Advance directive documentation was inconsistent for two residents. One resident’s POLST said no advance directive existed, while an Advance Directive Acknowledgement form said one had been executed, and the resident’s copy was not in the chart. For another resident, the POLST said no advance directive existed, but the resident and family both stated an advance directive was in place and the family had the copy; the SSD and DON were unaware of the conflicting information.
Psychotropic Medication Monitoring Deficiencies: Surveyors found that psychotropic meds were not properly tracked for target behaviors and non-pharm interventions were not documented for multiple residents. One resident’s poor PO intake was inconsistently monitored with a missing monthly summary, another resident’s Remeron, Risperdal, and trazodone records lacked accurate behavior counts and monthly summaries, and a third resident’s PRN Ativan use continued beyond the ordered 14-day period without documented MD rationale or behavior monitoring.
The facility failed to develop complete care plans for several residents with IV access devices and oxygen therapy. A resident with a central line and IV antibiotics, a resident with a midline IV, and a resident with a RUA PICC line all lacked care plan problems for line use and maintenance, despite physician orders for site care and monitoring. Another resident was receiving continuous O2 at 4 LPM even though the order was for 3 LPM, and the care plan only stated to give oxygen as ordered.
A resident who was ordered to receive one-to-one feeding assistance and documented as needing total assist was observed with a meal tray placed in front of her without staff present to help. She stated she had been waiting for help, could not see her meal, and was unable to eat the rest of her food. Staff later indicated they assumed another assigned CNA would provide the feeding assistance, and the resident’s care plan did not address her total feeding needs.
Inadequate supervision and incomplete post-fall documentation: A resident with repeated falls was assigned a sitter for safety, but the sitter left the room or was distracted while the resident fell, and the resident was also not visible for an observed 11-minute period because the privacy curtain blocked the view. The facility also had incomplete neuro checks and inaccurate or blank fall risk assessments after falls, according to the DON and record review.
GT Placement and Medication Administration Errors: An LVN failed to check gastric residual and did not flush the GT between medications for one resident receiving multiple GT meds, despite orders for residual checks and water flushes. For another resident, an LVN started a GT feeding without verifying tube placement before the flush and feeding. The DON confirmed the facility expected GT placement verification and residual checks before GT meds and feedings.
The facility failed to maintain IV access care and documentation for multiple residents receiving IV therapy. One resident had a central line in the chest with no correct physician order for care and maintenance, while another had a midline with an undated dressing and missing documentation for flushes, site checks, and catheter measurements. A third resident’s PICC dressing and required external length and arm circumference measurements were not documented as ordered, and a fourth resident’s midline lacked an order for care and maintenance and was not changed weekly as required.
Respiratory care deficiencies were identified when an SSD was observed turning a resident’s oxygen concentrator off and on despite not being trained to manage the equipment, a resident ordered continuous O2 at 3 LPM was found receiving 4 LPM, one resident’s nasal cannula tubing was undated and on the floor, another resident’s O2 administration was not documented on the MAR, and a resident received continuous O2 without a physician order or related care plan entry.
Failure to document and follow PRN pain medication parameters. The facility gave PRN opioid pain meds to three residents without documenting non-pharmacological pain interventions first, and one resident received oxycodone outside the ordered pain range. The DON and an LVN verified that the PRN meds should have been given only as ordered and that non-pharmacological interventions should have been attempted and documented before administration.
A resident with ESRD and dialysis dependence was observed receiving peritoneal dialysis in bed, with the dialysate infusing via gravity and the drainage bag on the floor. Review of the record and facility policy showed no physician order for the PD treatment or documented assessment of the access site before, during, and after dialysis. RN verified the resident received PD twice daily but could not show an order or ongoing catheter care documentation.
Inaccurate documentation of controlled pain medication administration. A resident’s record showed Oxycodone/APAP tablets were removed from the med supply on multiple occasions, but the MAR did not document that the doses were administered. During a concurrent record review, the DON verified the missing documentation and stated controlled meds should be documented on both the controlled drug record and the MAR.
The facility failed to ensure the consultant pharmacist completed monthly MRRs that identified medication irregularities for two residents. One resident’s MRR did not address the use of risperidone, trazodone, and mirtazapine, and another resident’s record showed mirtazapine ordered for poor PO intake with inconsistent meal monitoring, but the July MRR did not note the irregularities. The DON and RN acknowledged the missing and inaccurate documentation.
A resident with HTN received metoprolol despite a physician order to hold the medication when SBP was below 120 mmHg or HR was below 60 bpm. MAR review showed multiple doses were given when SBP was under the ordered parameter, and an LVN verified the administrations should have been held. The DON stated nurses were expected to check vital signs against the ordered parameters before giving BP meds.
Medication administration errors exceeded the allowed rate, with an observed error rate of 29.63%. An LVN failed to fully administer several GT medications to a resident with a GT and nebulizer treatments, left residue in medication cups and the nebulizer cup, and gave incorrect doses of simethicone and polyethylene glycol. Another LVN gave carvedilol to a resident with hypertension without first obtaining the required heart rate, despite an order to hold the medication if the HR was below 60 bpm.
Improper Medication Labeling and Storage: An opened 0.9% sodium chloride flush was found in a resident room instead of secured in the IV cart, a bottle of Multivite and a bottle of LiquaCel had sticky brown residue on them, and expired medical supplies were found in Medication Room B and Medication Cart C. An unopened Lispro insulin pen for a resident was also stored at room temperature in a medication cart, and staff acknowledged the storage and cleaning issues.
Improper Texture Modification of Meat: A resident with DM and dysphagia was ordered a regular diet with SB6 meat texture, but at lunch the resident was served a hot dog in large chunks that did not meet the SB6 standard. The SLP reviewed the meal photo and confirmed the meat was not prepared to the required texture.
The facility failed to ensure food brought in by family and visitors for resident consumption was stored for future use. The policy required outside food to be approved by nursing, match the diet order, and be eaten within 2 hours with leftovers discarded, and staff confirmed there was no refrigerator available to store visitor-brought food for resident use. The issue affected residents on oral diets.
Improper Disposal of Organic Waste: The facility failed to separate organic food waste from regular trash. During an observation of the dumpster area with the DSS, two organic waste bins were found empty, dry, and unused, and the DSS verified that kitchen staff were discarding organic food waste into the regular trash bin instead of the organic trash bin.
Staff failed to consistently follow EBP during resident care and cleaning activities. Observations showed a housekeeper cleaning a bedside table without a gown, a CNA assisting a resident with a catheter, GT site, and dialysis site without a gown, an LVN providing GT meds, an injection, and a neb treatment without a gown, another LVN performing wound care while handling an open box of gloves on the resident’s mattress, and an LVN whose untied gown fell away during GT feeding. The report also noted a resident with a PICC line was not properly reflected on the EBP list and signage.
Failure to Offer and Document COVID-19 Vaccination: The facility failed to educate, offer, and document the current COVID-19 vaccine status for three residents reviewed for immunizations. Medical record review showed each resident had previously received a COVID-19 dose, but there was no documentation that they were offered another recommended dose or that they refused or had a contraindication, despite the facility policy requiring education, offering the vaccine, and documenting each dose or refusal.
Staff Training and Competency Deficiencies: A resident with a tracheostomy and oxygen order was observed while an SSD turned the oxygen concentrator off and on despite having no training to manage or troubleshoot the equipment, and the DON confirmed this was outside the SSD's scope. The facility also failed to fully document an annual competency evaluation for an LPN and could not document that 11-7 shift staff received two required in-services.
Inaccurate MDS coding was identified for two residents. One resident’s MDS did not reflect oxygen use documented in the chart and skilled notes, while another resident’s discharge MDS showed one fall even though the record documented three falls during the look-back period. The MDS Coordinator reviewed both records and verified the coding errors.
The facility failed to revise and resolve care plans for two residents after the related IV therapy/IV antibiotics and quetiapine were completed or discontinued. The DON confirmed that one resident’s IV tx and ABX for a UTI had ended and the other resident’s quetiapine had been stopped, but the care plans remained active and were not updated to reflect those changes.
A facility failed to keep resident records accurate when a deceased resident had temperature and pain assessments documented after death, and when MAR entries for PRN narcotic pain meds did not match the doses removed from the controlled drug records for two other residents. The DON verified the deceased resident’s charting was inaccurate, and stated the nurses had administered the doses removed but incorrectly documented the MAR entries.
A facility failed to ensure 16 resident rooms met the minimum required 80 square feet per resident. Review of the Client (Resident) Accommodations Analysis form showed multiple rooms measured below the required square footage, and the Administrator verified the rooms did not meet the minimum standard during interview and document review.
A resident with suspected financial abuse did not receive the required care plan interventions, as staff failed to implement or communicate protective measures such as increased monitoring and supervision during visits from the alleged perpetrator. Key assessments and documentation were not completed, and staff were not informed of the situation, leaving the resident without appropriate safeguards.
Licensed staff failed to complete required sections of the Dialysis Communication Forms for two residents undergoing hemodialysis, omitting documentation of access site status and general condition before and after treatments, despite physician orders and facility policy. Both the RN and DON acknowledged the importance of these assessments and the incomplete records.
A facility failed to provide a resident with a bed hold for up to seven days upon readmission, placing them in a different room despite available beds in the original room. Additionally, the facility did not provide the resident or their representative with a written bed hold policy upon transfer to a hospital, as required by facility policy. The DON and RN Consultant confirmed the lack of notification, and the Administrator acknowledged the findings.
A long-term care facility failed to implement effective infection control practices, leading to a deficiency. A resident with salmonella was improperly cohorted with another resident, increasing the risk of contamination. Staff, including an RN and a caregiver, did not adhere to PPE protocols, such as hand hygiene and wearing gowns, while providing care. Additionally, a visitor was observed without proper PPE. The facility's policies for transmission-based and standard precautions were not effectively followed, compromising the safety and sanitary environment.
A resident experienced a failure in care when the facility did not monitor their forehead wound and arm skin breakdown every shift as ordered. The resident had a fall resulting in a forehead laceration, and the TAR showed missed assessments. Additionally, the facility did not notify the physician of documented skin breakdowns, as confirmed by interviews with the LVN and DON.
A facility failed to ensure a resident with an order for thickened liquids was evaluated by a speech therapist (ST) as per policy. The resident, unable to make decisions, had orders for nectar consistency liquids, but the care plan lacked this detail. Interviews revealed the RD expected the ST to evaluate liquid consistency, but the ST confirmed no evaluation was done.
The facility failed to assess five residents' ability to handle hot liquids, leading to incidents where two residents with severe cognitive impairment were injured by hot beverages. The facility's policy required such assessments, but they were not conducted, as confirmed by staff interviews and medical record reviews.
A resident requiring nectar-thick liquids was served regular consistency coffee, revealing a lack of staff training and knowledge in preparing thickened beverages. Despite facility policies, CNAs and nurses were responsible for preparation without adequate guidance, leading to potential aspiration risks.
A resident's family reported that the resident felt intimidated by a CNA's care, which was not reported or investigated by the facility as required by their Abuse, Neglect, and Exploitation P&P. The DON and Administrator were aware of the allegation but failed to notify the State Agency or conduct an investigation, posing a risk to resident safety.
A resident was improperly transferred/discharged from a facility after exceeding her out-on-pass time and missing medications. Upon her return, the facility did not allow re-entry, failed to notify her physician, and did not conduct an assessment. The resident was taken to an emergency department, where she experienced elevated blood pressure and low oxygen saturation. The facility did not provide necessary documentation or coordinate a safe transition of care.
A facility failed to provide a required transfer/discharge notice to a resident and their representative before initiating a discharge against medical advice. The resident, who had decision-making capacity, was not informed of their appeal rights or the specific location for transfer. The facility's administrator confirmed the failure to adhere to policies requiring such notice.
A resident in an LTC facility did not receive adequate care for pain and skin conditions. The resident's pain was not fully assessed, and non-pharmacological interventions were not offered before administering medication for severe pain, despite the resident reporting moderate pain. The physician was not informed, and documentation was lacking. Additionally, the resident's skin issues were not comprehensively assessed, and there was no care plan in place. Interviews with staff confirmed these deficiencies.
A resident with impaired cognition and a history of falls was left unattended after requesting assistance to use the bathroom. Despite informing a CNA, the resident did not receive help due to a lack of communication and follow-up among staff. The resident attempted to transfer herself to the toilet, resulting in a fall and a fractured right humerus, requiring hospitalization.
A facility failed to document necessary indwelling urinary catheter care for a resident, as required by their policy. The medical record review showed missing documentation for catheter care on multiple occasions, despite the facility's policy mandating care every shift. Interviews with an LVN and the Infection Preventionist confirmed the lack of documentation and assessment, with the LVN admitting to performing care without documenting it. The Infection Preventionist was also unable to provide the required care plan documentation.
The facility did not follow its policy regarding the management of a resident's personal belongings after the resident's death. The inventory list was not provided to the family, and there was no documented communication about the belongings' disposition. Interviews with staff confirmed the oversight, as the Social Worker did not follow up with the family, and the Director of Medical Record acknowledged the failure to provide the inventory list.
A resident's bedside commode was found rusty and corrosive, and despite the resident informing staff, it was not replaced promptly. The DON was aware and intended to inform maintenance, but the issue persisted, as confirmed by the DSD.
The facility did not meet room size requirements, lacking waivers for rooms under the required 80 square feet per resident. Although a waiver was approved in 2019, none were obtained for 2023 and 2024. The Administrator was unaware of the waiver requirement due to a lack of transition from the previous administrator, and the Maintenance Director confirmed the non-compliance of 16 rooms.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illnesses for 75 residents. Observations revealed wet-stored kitchen equipment, unsanitary cutting boards, undocumented thawing of bacon, and an unclean ice machine. These issues were confirmed by the Dietary Supervisor and other staff.
The facility failed to assess three residents for safe self-administration of medications, as required by policy. A resident with Lung Cleansing Spray, another with hydrocortisone and pain relief creams, and a third with antifungal powder were found with medications at their bedsides without physician's orders, assessments, or care plans. Staff confirmed the lack of necessary documentation and evaluations.
Failure to Document Resident Belongings at Discharge
Penalty
Summary
The facility failed to follow its discharge process for resident personal belongings for one of five sampled residents. Facility policy on Resident Personal Belongings required the protection of residents' rights to possess personal items and to ensure those belongings were rightfully returned to the resident or representative upon death or discharge. A separate policy on Documentation in Medical Record required that licensed staff and the interdisciplinary team document all assessments, observations, and services in the medical record to provide a clear picture of the resident’s experiences and progress. For Resident 1, who was cognitively intact per the MDS assessment, the Resident's Clothing and Possessions form dated 12/12/25 contained two sections: "On Admission" and "On Discharge." The "On Admission" section listed items brought in at admission, while the "On Discharge" section had only a slash across it with the notation "discharge AMA," and no itemized listing of belongings. During interviews and concurrent closed medical record reviews, staff confirmed that the discharge section of the belongings form for this resident was incomplete. CNA 5 verified that the "On Discharge" section was not filled out and stated that the resident’s belongings should have been counted and sorted by a licensed nurse or CNA, placed in a bag labeled with the resident’s name, and then given to social services. RN 2 also confirmed the form was incomplete and stated that the licensed nurse or CNA team lead should have completed the form to ensure no items were missing. The DON acknowledged these findings and stated that the form should have been completed when staff packed the resident’s belongings, with the person packing the items specifying them on the form so the facility would have an accurate account of the resident’s belongings.
Failure to Obtain and Document Physician Order for Podiatry Appointment
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a physician’s order for a resident’s podiatry appointment, as required by facility policy and practice. The facility’s Transportation policy stated that social services would assist residents with arranging transportation as needed, and the Documentation in Medical Record policy required that licensed staff and the interdisciplinary team document all services provided in the medical record. The resident in question was cognitively intact, had been admitted and later discharged from the facility, and on the day of discharge walked out of the facility to a bus stop stating she had an appointment and was leaving. A progress note documented that the bus picked up the resident and that the physician was made aware. During closed record review, the resident’s order summary failed to show any physician’s order for the podiatry appointment on that date. RN 2 stated that licensed nurses typically enter appointment orders on behalf of the physician and determine transportation and companion needs, and verified that no such order existed for this resident’s podiatry visit. The Social Services Assistant confirmed that the resident had scheduled a podiatry appointment and acknowledged that a physician’s order was needed for the resident to go to the appointment. The DON also verified there was no physician’s order for the podiatry appointment despite social services knowing about it, and stated there should have been an order so all departments would be aware of the appointment. RN 1 reported that, in usual practice, she would enter the physician’s order for any appointment into the EMR, print it, and provide it to social services, and that physicians usually write such appointments in their orders, but she could not recall being informed of this specific podiatry appointment.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services by not notifying a resident's physician when there was a significant change in the resident's condition, specifically a change in urine color from yellow to dark amber. According to the facility's policy and procedure on Notification of Changes, staff are required to inform the physician and the resident or their representative when there is a change that requires such notification. Review of the resident's closed medical record showed documentation by an LVN of the change in urine color, but there was no evidence that the physician was notified of this change. Interviews with the LVN, the physician assistant (PA), and the Director of Nursing (DON) confirmed that the physician was not notified about the resident's dark amber urine. The LVN acknowledged observing and documenting the change but did not report it to the physician, and both the PA and DON verified that there was no documentation of physician notification in the medical record. The failure to notify the physician occurred despite the facility's policy requiring such action when a resident experiences a change in condition.
Failure to Follow Physician's Order for PRN Medication Administration
Penalty
Summary
A deficiency occurred when a licensed nurse administered two tablets of Tylenol (acetaminophen) 325 mg to a resident for a temperature of 99 degrees Fahrenheit. The physician's order specified that acetaminophen was to be given via gastrostomy tube (GT) every six hours as needed for fever, but only if the resident's temperature exceeded 100.5 degrees Fahrenheit. The medication administration record (MAR) confirmed that the medication was given outside the parameters of the physician's order. Interviews with the involved LVN and the facility's QA Nurse verified that the medication was administered contrary to the physician's instructions. The QA Nurse acknowledged that the nurse failed to follow the order, and the Director of Nursing (DON) was informed and acknowledged the findings. The resident in question had been readmitted to the facility and subsequently expired, but the report focuses on the medication administration event and the failure to adhere to the prescribed order.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
Food safety and sanitation guidelines were not followed in the kitchen when pasteurized eggs were not available for a resident who requested fried over easy eggs every morning with breakfast. Facility staff initially used shell eggs from a case labeled SEFS complaint eggs and stated they were pasteurized, but the invoice later showed the eggs were not pasteurized. The resident was on a regular texture CCHO diet, was alert and oriented, and verified that she preferred two over easy fried eggs every morning with breakfast. The RD stated pasteurized eggs should always be available, but also stated they were not included in the monthly kitchen audit. Additional kitchen sanitation issues were observed during the tour. Four fry pans had greasy, black residue and food debris on the cooking surfaces. Three small steamtable pans were stacked together with water residue between them. A food preparation sink located next to the dish machine had no air gap or backflow prevention, and four plastic bins of dry cereal were found in a dry storeroom that was 90 degrees F with a use-by date of 8/1/25. The DSS verified the findings related to the pans, sink, and cereal storage.
Call Light Not Functioning for Resident With Closed Door Preference
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the needs and preferences of Resident 29 by not ensuring the resident’s call light was functioning properly. Resident 29 was admitted to the facility on 5/24/25 and had a care plan addressing fall risk, with an intervention to keep the call light within reach at all times. During a resident council meeting, Resident 29 reported that her call light had not been functioning for about two weeks and that she had been given a call bell to use when she needed assistance. She stated she had to wait longer for nurses when she needed help. During observation and interview, Resident 29 was found in bed with the call bell on the over-bed table, and she stated her bedroom door was kept closed at all times per her preference. When she tested the call light, the indicator above her door did not flash, and the nurse’s station alarm sounded without identifying which room needed assistance. Staff at the nurse’s station could not determine which resident had activated the call light and had to ask other staff to check their assigned residents. Resident 29 stated she was worried staff might not come right away if she needed urgent assistance and said the call bell did not work well when her door was closed. She also stated she needed to be turned and repositioned every two hours and sometimes had to remind staff because they did not respond right away.
Advance Directive Documentation Was Inconsistent for Two Residents
Penalty
Summary
The facility failed to clarify and follow up on residents’ rights to formulate advance healthcare directives for two sampled residents, Residents 28 and 85. Facility policy stated that on admission the facility would determine whether a resident had executed an advance directive and, if so, make copies and place them in the chart. For Resident 28, the medical record contained a POLST dated 5/7/25 stating there was no advance directive, but an Advance Directive Acknowledgement form dated 5/5/25 showed the resident had executed an advance directive. The record also did not contain documented evidence of the resident’s copy of the advance directive. For Resident 85, the medical record contained a POLST dated 7/21/25 stating there was no advance directive, but an Advance Directive Acknowledgement form dated 7/27/25 showed the resident did not execute an advance directive. During interview, Resident 85 stated she had an advance directive and that her daughter had the copy, and the family member verified that the resident had an advance directive and said the facility had not asked for a copy. The SSD stated he was not aware of the conflicting advance directive information for Residents 28 and 85, and the DON verified the findings.
Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that psychotropic medications were monitored for the identified target behaviors and that non-pharmacological interventions were documented for three sampled residents. The report states that the facility’s policy required psychotropic medications to be used only when appropriate for a specific, documented condition and that non-pharmacological interventions be attempted unless clinically contraindicated. Surveyors reviewed medical records, monitoring forms, medication orders, and interviewed staff, and found that the required behavior monitoring and documentation were not consistently completed for residents receiving mirtazapine, risperidone, trazodone, and PRN lorazepam. For one resident with depression, mirtazapine was ordered for poor PO intake, with staff instructed to record the number of times the behavior was manifested every shift. The resident’s meal intake records showed multiple instances of eating less than 50% of meals, but the behavior monitoring form for the month documented zero episodes. The record also did not contain a monthly behavior monitoring summary for the medication. Staff interviews showed inconsistent understanding of the threshold for counting poor intake, and the DON acknowledged the inaccurate monitoring and missing summary. For another resident receiving Remeron, Risperdal, and trazodone, the record showed orders to monitor poor PO intake, auditory hallucinations, and inability to sleep, respectively, and to document the number of times each behavior occurred every shift. Surveyors found blank entries on the monitoring record for some shifts, and the psychopharmaceutical summary sheets did not contain monthly behavior monitoring summaries for June and July 2025 for risperidone and trazodone, or for July 2025 for Remeron. The QA Nurse stated the CNA meal intake documentation did not match the behavior monitoring form and could not provide documentation showing non-pharmacological interventions were provided before the medications were used. For a third resident, PRN Ativan was ordered for anxiety manifested by inability to relax, with each order limited to 14 days. The resident received multiple doses in July and August 2025, but the medical record did not show the physician’s clinical rationale for continuing the medication beyond the 14-day period. The record also lacked the monthly behavior monitoring summary for July 2025 and did not show that non-pharmacological interventions were implemented before PRN Ativan was administered. The DON reviewed the record and verified these omissions.
Missing Care Plans for IV Access and Oxygen Therapy
Penalty
Summary
The facility failed to develop comprehensive care plans that reflected the individual care needs of four sampled residents. Resident 3 had a two-lumen central line in the left upper chest and was receiving piperacillin IV every 12 hours for a wound infection, with physician orders for PICC site maintenance, dressing changes, and measurement of external catheter length and arm circumference. Review of the care plan showed no documented problem addressing the central line or IV antibiotic therapy, and RN 1 verified that no such care plan had been developed. Resident 5 had a midline IV with physician orders for site maintenance, including measurement of external catheter length and arm circumference. The resident’s care plan addressed skin alterations and included administering IV antibiotics and monitoring for side effects, but it did not include a care plan problem for the use and maintenance of the midline IV. RN 1 reviewed the record and was unable to show documentation for a care plan addressing the midline. Resident 8 had an order for continuous oxygen via nasal cannula at 3 LPM, and the care plan directed oxygen to be administered as ordered. During observation, the resident was receiving oxygen at 4 LPM, and the resident stated the nurses had set the rate. LVN 2 reviewed the order and care plan, confirmed the ordered rate was 3 LPM, and lowered the oxygen to 3 LPM. Resident 59 was admitted with a right upper arm PICC line with two lumens, had orders for PICC/midline dressing changes and measurement of external catheter length and arm circumference, but the care plan did not include a problem addressing the PICC line. RN 2 and the DON both verified that a care plan should have been developed for PICC line management.
Failure to Provide Ordered Feeding Assistance
Penalty
Summary
The facility failed to ensure feeding assistance was provided per the physician’s order for Resident 5, who was ordered to receive one-to-one feeding assistance and was documented on the meal card as requiring total assistance with feeding. Review of the care plan showed a nutritional problem was addressed, but there was no care plan addressing the resident’s need for total assistance with feeding or interventions for one-to-one assistance during meals. The resident was also described by staff as totally blind and needing total assistance with feeding. During the dining observation, Resident 5 was found sitting up in bed with a closed lunch tray and utensils placed in front of her, waiting for staff assistance. The resident stated she had been waiting for staff for 10 minutes, could not see her meal, and had not been told whether staff would return or help set up the tray. She was observed feeling around the tray, lifting the cover, locating utensils, and attempting to eat with difficulty, including using her hands to eat some food. The resident later stated she needed help feeding and could not eat the rest of her food, and her call light remained on while no staff were present in the hallway. Staff later stated they believed another assigned staff member would provide the feeding assistance, and the DSD confirmed that the assigned CNA had arrived late and gone on break.
Inadequate supervision and incomplete post-fall documentation
Penalty
Summary
The facility failed to ensure Resident 10 remained free from accident hazards and received adequate supervision to prevent accidents. Resident 10 had a history of multiple falls after readmission to the facility, and the care plan identified both an actual fall problem and a fall risk problem with interventions to monitor the resident more frequently, anticipate and meet needs, and follow the facility's fall protocol. The record showed falls on 3/22, 4/1, 4/3, 6/27, 7/12, 7/27, and 8/5/25. The record and staff interviews showed Resident 10 sustained falls while the assigned sitter was distracted or had left the room. For one fall, the sitter left the resident's room while the resident was sleeping, and the resident was later found on the floor stating he tried to get to the bathroom. For another fall, the sitter was assisting the roommate when Resident 10 fell. For the 8/5/25 fall, the resident had an unwitnessed fall and was found on the floor. The DON stated the sitter's role was to monitor the residents for safety and should not have left the room or provided care that prevented monitoring. The facility also failed to complete required post-fall documentation. The post-fall neurological flow sheet for the 4/3/25 fall was incomplete because the final neurological assessment was not completed, and the 8/5/25 neurological flow sheet had incomplete assessments numbered 15, 16, and 18. In addition, the 7/27/25 fall risk assessment incorrectly documented no falls in the past three months, and the 8/5/25 fall risk assessment was blank. During observation on 8/8/25, Resident 10 was not visible from the doorway because the privacy curtain was fully closed, and the CNA assigned as sitter was unable to explain how she was monitoring the resident during that time.
GT Placement and Medication Administration Errors
Penalty
Summary
The facility failed to provide appropriate care and services related to gastrostomy tube (GT) use for two residents. One resident had physician orders to flush the enteral feeding tube with water before and after medication administration and to check gastric residual every shift, holding feedings if residual exceeded 100 ml and rechecking in one hour if needed. The resident also had a care plan addressing GT feeding, including checking GT placement and gastric residual volume per facility protocol and providing water flushes with medications. During a medication administration observation, an LVN prepared multiple GT medications for the resident, including Juven, vitamin C, docusate sodium, simethicone, LiquaCel, MultiVite Liquid, and polyethylene glycol. The LVN was observed checking GT placement by injecting air and auscultating the abdomen and flushing the tube with 30 ml of water before giving the medications, but did not check the gastric residual volume before administration and did not flush the GT with water between each medication. In interview, the LVN acknowledged not checking the residual and not flushing between medications, while the DON stated nurses were expected to check GT placement and gastric residual and to flush before, after, and between medications. A second resident had an order to receive Osmolyte 1.2 via GT daily. During observation of the tube feeding, an LVN checked residuals, found none, flushed the GT, and started the feeding without first verifying GT placement by auscultation. The LVN stated placement only needed to be verified once per shift and that it had been verified earlier during morning medication administration. The DON later confirmed the facility policy required GT placement to be verified with auscultation before administering water flushes, tube feeding, and GT medications.
IV Access Care and Documentation Deficiencies
Penalty
Summary
The facility failed to provide necessary care and services to maintain IV accesses for four residents receiving IV therapy. The report states that the facility did not ensure physician orders were in place for the use and maintenance of one resident’s central line and another resident’s midline, did not ensure weekly dressing changes were completed as ordered for two residents, and did not ensure required documentation of IV maintenance activities was completed for multiple residents. These failures were identified through observation, interview, medical record review, and review of facility policy and procedure. One resident was observed with a two-lumen central line in the left upper chest while receiving IV antibiotics for a wound infection. The medical record showed orders for IV antibiotic administration and for PICC line dressing changes and measurements, but the August order summary did not show a physician’s order for the IV central line care, maintenance, and monitoring. Staff confirmed the resident’s central line had been placed at an acute care hospital, and the record lacked documentation for the IV access central line. The physician’s order for the resident’s IV access site was acknowledged by staff to be incorrect and inaccurate. Another resident was observed with a left upper arm midline and an undated dressing. The record showed orders for IV antibiotic therapy, normal saline flushes, site checks, and measurement of the midline external catheter length and arm circumference, but documentation was missing for several medication administrations, flushes, site checks, and measurements across July and August. Staff also acknowledged that the midline dressing was undated and that the actual measurements for the external catheter length and arm circumference should have been documented. A third resident had a right upper arm PICC line with a dressing dated several days earlier, and the record lacked baseline and follow-up documentation of external catheter length and arm circumference measurements. A fourth resident had a left upper arm midline with a dressing dated before admission, but the record failed to show a physician’s order for the midline care and maintenance and failed to show that the dressing had been changed weekly.
Respiratory Care and Oxygen Therapy Deficiencies
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident with a tracheostomy and for four residents receiving oxygen therapy. For the resident with a tracheostomy, the physician ordered oxygen via tracheostomy collar at 5 LPM with titration to keep oxygen saturation at or above 92%, and the care plan identified altered respiratory status related to tracheostomy, CHF, and chronic respiratory failure. During an observation, the SSD was seen turning the resident’s oxygen concentrator off and on while trying to troubleshoot a beeping machine, and the SSD stated he did not have training specific to managing the oxygen concentrator and should have contacted the nurse instead. The DON later stated that turning off the oxygen concentrator was not within the SSD’s scope of practice and could result in negative health outcomes for the resident. For another resident, the physician ordered continuous oxygen via nasal cannula at 3 LPM, but the resident was observed receiving oxygen at 4 LPM. A licensed nurse later reviewed the order, confirmed the ordered rate was 3 LPM, and lowered the oxygen to match the physician’s order. The resident stated that the licensed nurses at the facility had set the oxygen rate. The facility also failed to document oxygen administration on the MAR for a resident with a PRN oxygen order. Progress notes showed multiple instances where the resident received oxygen via nasal cannula, but the MAR for July and August 2025 did not show the oxygen was administered. In addition, one resident’s nasal cannula tubing was observed unlabeled, undated, and touching the floor, and the DON verified those findings. Another resident was receiving continuous oxygen via nasal cannula without a physician’s order for oxygen, and the resident’s record also lacked a care plan problem addressing oxygen use. The resident stated she had been receiving continuous oxygen for about four to five days, and staff verified the absence of an order and the undated tubing.
Failure to document and follow PRN pain medication parameters
Penalty
Summary
The facility failed to provide safe, appropriate pain management for three sampled residents who had PRN pain medication orders. The facility's pain management policy stated that pain interventions should be developed, implemented, monitored, and revised as needed, and that non-pharmacological interventions could include environmental comfort measures, physical modalities, and cognitive/behavioral interventions. The policy also stated that pharmacological interventions should follow a systematic approach and be specific to each resident with pain. For Resident 59, the record showed PRN oxycodone orders for moderate pain at 4 to 6 and severe pain at 8 to 10, but the medication was administered on multiple occasions when the documented pain level was 7, which was outside the ordered parameters. The record also failed to show that non-pharmacological pain interventions were implemented and found effective before the PRN oxycodone was given. During interview and record review, an LVN verified that the medication should have been administered only within the ordered pain parameters and stated the order should have been clarified with the physician. For Resident 85, the record showed a PRN hydrocodone-acetaminophen order for moderate to severe pain, and the medication was administered multiple times. The record failed to show documentation that non-pharmacological pain interventions were implemented and effective before those doses were given. For Resident 10, the record showed a PRN hydrocodone-acetaminophen order for moderate to severe pain, and the medication was administered twice, but the record also failed to show that non-pharmacological interventions were attempted before administration. The DON and LVN verified that non-pharmacological interventions should have been attempted and documented before PRN pain medication was given.
Missing Physician Order and Dialysis Access Monitoring
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for Resident 28, who was admitted with end stage renal disease and dependence on dialysis. During the initial tour, the resident was observed awake in bed with a dialysate bag hanging on an IV pole and infusing by gravity through the peritoneal dialysis access site on the abdomen, with the drainage bag on the floor. The resident stated the dialysis was done two times a day every day, in the morning and afternoon, for about three to four hours. Review of the facility policy for peritoneal dialysis showed that physician orders must include the individualized dialysis prescription and that staff must obtain vital signs, weights, assess the resident’s stability, level of consciousness, comfort or distress, and document ongoing evaluation of the peritoneal catheter and access site before, during, and after dialysis. However, the resident’s August 2025 order summary did not show a physician’s order for peritoneal dialysis at the bedside, including assessment of the access site before, during, and after dialysis. The medical record also did not contain documented evidence of assessment before, during, and after dialysis. RN 1 verified the resident received peritoneal dialysis twice daily and acknowledged there was no physician’s order for it and no documentation for ongoing catheter care monitoring and assessment.
Inaccurate Documentation of Controlled Pain Medication Administration
Penalty
Summary
The facility failed to ensure accurate controlled medication records for Resident 87, whose closed medical record was reviewed after the resident had been readmitted and later discharged from the facility. Review of the resident’s Antibiotic or Controlled Drug Record for Oxycodone/APAP 5-325 mg tablets showed that tablets were removed from the medication supply on four occasions, including one removal on 10/31/25 at 1330, one on 11/4/24 at 1030, and two on 11/22/24 at 0811 and 0900. However, the resident’s MARs for October and November 2024 did not show documentation that these tablets were administered to account for why they were removed from the medication supply. During an interview and concurrent record review, the DON verified the findings and stated that when controlled medications are removed from the supply, they should be documented on both the Antibiotic or Controlled Drug Record and the MAR to show administration to the resident.
Pharmacist MRR Failed to Identify Psychotropic and Meal-Intake Monitoring Irregularities
Penalty
Summary
The facility failed to ensure the consultant pharmacist completed the required monthly Medication Regimen Review for two sampled residents and identified medication irregularities documented in their records. The facility’s Medication (Drug) Regimen Review policy required a comprehensive review at least monthly, including evaluation of the resident’s response to medication therapy and the medical chart. Survey review of the Medication Regimen Review binder and resident records showed that the consultant pharmacist did not document a monthly review for one resident in June and July 2025 that addressed the use of risperidone, trazodone, and mirtazapine, all of which were ordered for schizophrenia, sleep, depression, or poor PO intake. For that resident, the order summary showed risperidone 0.5 mg twice daily and 1 mg at bedtime for schizophrenia with auditory hallucinations, trazodone 100 mg at bedtime for depression with inability to sleep, and mirtazapine 7.5 mg at bedtime for depression with poor PO intake. The DON confirmed the resident should have had monthly pharmacist reviews for June and July 2025 that specifically addressed these psychotropic medications, but the facility’s MRR binder did not show such reviews for the resident. For another resident, the record showed an order for mirtazapine for depression manifested by poor intake of less than 50% of each meal, along with an order to monitor and record the behavior every shift. The resident’s nutrition records showed multiple days of eating less than 50% of meals, but the behavior monitor record for July 2025 documented zero occurrences, and the medical record did not contain a monthly behavior summary. The consultant pharmacist’s July 2025 MRR for this resident did not identify any irregularities, and both RN 1 and the DON acknowledged that the monitoring of poor intake was inaccurate and that no monthly summary had been completed.
Improper Administration of BP Medication Despite Hold Parameters
Penalty
Summary
Resident 59 was found to have received metoprolol 25 mg every 12 hours despite a physician order to hold the medication when systolic blood pressure was less than 120 mmHg or heart rate was less than 60 beats per minute. The resident had a care plan addressing risk for complications related to hypertension, with interventions to administer antihypertensive medications as ordered and to observe blood pressure and pulse monitoring parameters before administration. Review of the August 2025 MAR showed metoprolol was administered on multiple occasions when the resident's systolic blood pressure was below the ordered parameter, including readings of 118/60, 110/68, 118/72, 116/75, and 118/66 mmHg. During interview and concurrent record review, the LVN verified these administrations and stated the medication should have been held per the physician's order. The DON stated licensed nurses were expected to compare vital signs with ordered parameters before giving blood pressure medications, and the Administrator, DON, and Nurse Consultant were informed of the findings.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5%, and the observed error rate was 29.63%. During medication administration observations, two licensed nurses made errors while giving medications to two residents. The facility’s medication administration policy required medications to be given as ordered, with vital signs obtained and recorded when applicable or per physician order, and to compare the medication source with the MAR to verify the resident name, medication name, form, dose, route, and time. For one resident with a gastrostomy tube and nebulizer treatments, an LVN administered multiple medications through the GT and was observed combining MultiVite liquid with polyethylene glycol before the first medication was fully administered. After the GT medications were given, significant residue remained in several medication cups, including white-colored medication residue, brown-colored liquid, and orange-colored powder mixture. The LVN also did not check the nebulizer cup after treatment, and medication remained in the cup. The resident’s order summary showed simethicone 80 mg via GT and polyethylene glycol powder 1450 17 gm via GT, but the LVN administered simethicone 125 mg and polyethylene glycol powder 3350 instead. For another resident receiving carvedilol for hypertension, the LVN obtained the blood pressure but did not obtain the resident’s heart rate before administering carvedilol 12.5 mg, despite the order to hold the medication if the heart rate was less than 60 beats per minute. The LVN later checked the heart rate after the medication had already been given and found it was 70 beats per minute. The DON, Administrator, and Nurse Consultant were informed of the findings.
Improper Medication Labeling and Storage
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored in accordance with facility policy and accepted medication storage practices in Medication Room B and Medication Carts A, B, and C. During observation and interview, an opened 10-ml syringe of 0.9% sodium chloride flush was found on top of the alcohol-based hand rub dispenser in a resident room, and RN 1 stated these flushes should be stored in the IV carts and not kept at the resident’s bedside or in resident rooms. In Medication Cart B, a bottle of Multivite and a bottle of LiquaCel were observed with a sticky brown residue on the bottles, and LVN 3 stated the assigned nurse was responsible for cleaning the cart and ensuring stains on medication bottles were cleaned before returning them to the cart. Expired medical supplies were also found in storage areas and medication carts. In Medication Room B, expired vacutainers, culture swabs, an ova and parasite stool specimen container, and a box of syringes with needle sets were observed, and RN 1 stated expired supplies should not be kept in medication rooms. In Medication Cart C, expired Mefix tape, syringes with needle sets, Povidone-Iodine swab sticks, and Huber needle sets were observed, and RN 2 stated the licensed nurse assigned to the cart was responsible for checking the cart at the beginning of the shift and removing expired supplies. In Medication Cart A, an unopened Lispro insulin pen for Resident 50 was observed stored inside a clear bag at room temperature, and LVN 3 stated the insulin pen should be stored in the refrigerator until used and did not know how long it had been in the cart.
Improper Texture Modification of Meat
Penalty
Summary
The facility failed to ensure that Resident 67 received food prepared in a form that met the resident’s individual dietary needs. Resident 67 had diagnoses of type 2 diabetes mellitus and dysphagia. The physician’s order dated 6/18/25 directed a regular diet with regular texture and thin consistency per the SLP, with no raw vegetables and meat to be kept at SB6 texture. Facility documentation showed five residents were on a soft and bite-sized diet, and IDDSI guidance indicated soft and bite-sized meats should be no larger than 1.5 cm, or about 1/2 inch. During the lunch observation on 8/5/25, Resident 67 was initially without a meal tray and stated she was waiting for a hot dog. When the meal was served, the tray included a hot dog cut into large chunks, approximately one inch by half an inch, along with a hot dog bun, chopped cooked carrots, and chopped sweet potatoes. A photo of the meal was reviewed with the SLP on 8/6/25, and the SLP verified that the hot dog was not prepared to SB6 texture and stated it should have been cut into smaller pieces, either in half or thinner slices.
No Refrigerated Storage for Outside Food
Penalty
Summary
The facility failed to ensure that food brought in from outside sources for residents was stored for future consumption in a safe and sanitary manner. Surveyors observed that the facility did not provide refrigerated storage for residents' food brought from outside sources. Review of the facility's matrix dated 8/5/25 showed 62 residents were on an oral diet. Review of the facility policy titled "Outside Food Brought in by Family and Visitors" revised 1/25/24 showed food prepared by family or visitors and brought in for residents had to be approved by nursing to ensure it matched the diet order, be eaten within two hours of receipt, and have any remaining food discarded. During interview, LVN 8 confirmed that outside food for resident consumption had to be consumed within two hours and that the facility did not provide refrigerated storage for food brought from outside. The RD also confirmed the facility did not have a refrigerator to store food brought by visitors for resident consumption.
Improper Disposal of Organic Waste
Penalty
Summary
The facility failed to ensure organic trash was disposed of properly by not separating organic waste from regular trash. During an observation of the outside trash dumpster area with the DSS, two organic trash bins were seen behind the wall of the dumpster area; both bins were empty, dry, and appeared unused. When asked where kitchen staff discarded organic food waste from the kitchen, the DSS verified that the organic food waste was not separated from regular trash and was instead discarded in the regular trash bin in the kitchen. The report states this failure had the potential to increase the environmental impact of the facility and adversely impact all 71 residents who resided there.
Failure to Follow EBP During Resident Care and Environmental Cleaning
Penalty
Summary
The facility failed to implement infection prevention and control practices for residents placed on Enhanced Barrier Precautions (EBP) and for staff performing high-contact care activities. The report identified failures involving six sampled residents with wounds, feeding tubes, a PICC line, or other indwelling devices, and described observations in which staff did not consistently wear the required gown and gloves or otherwise follow the facility’s EBP signage and policy. For one resident with a right upper arm PICC line, the EBP sign outside the room showed a yellow sticker next to one bed but not the resident’s bed, and the facility’s EBP list did not show the resident as on EBP. The resident’s record showed admission with a PICC line and later a physician order to implement EBP related to the PICC line. During interview, RN staff stated the resident should have been on EBP because of the PICC line, while the IP stated residents on EBP should have a physician order and acknowledged the resident still had the PICC line. For another resident with chronic wounds on EBP, a housekeeper entered the room and wiped the bedside table without wearing a gown, despite the EBP sign indicating gowns and gloves were required for cleaning the environment. For a resident with a GT on EBP, an LVN administered medications via the GT, gave a heparin injection, and administered a nebulizer treatment without wearing a gown. For a resident with a catheter, GT site, and dialysis site on EBP, a CNA assisted the resident in bed, touched linens, and repositioned the resident without a gown. For a resident receiving wound care and on EBP for a dialysis site and chronic wound, an LVN performed wound care while using an open box of gloves placed on the resident’s mattress near the wound area, then moved that box for use on the wall holder. For a resident receiving GT feeding on EBP, an LVN wore a gown but did not tie it at the neck and waist, and the gown fell from the shoulders to the elbows during care.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to three of seven residents reviewed for immunizations: Residents 7, 17, and 18. Review of the CDC Recommended Adult Immunization Schedule showed routine COVID-19 vaccination recommendations for individuals age 65 years and older, and the facility’s policy stated that residents should be educated and offered the COVID-19 vaccine unless medically contraindicated, already immunized during the time period, or refusing the vaccine. The policy also required documentation in the medical record of each dose administered or documentation of medical contraindication or refusal. Medical record review showed Resident 7, age [AGE], had received a Pfizer COVID-19 booster on 6/3/22, Resident 17, age [AGE], had received a COVID-19 vaccine of unknown manufacturer on 4/9/21, and Resident 18, age [AGE], had received a Moderna COVID-19 booster on 11/12/21. For each of these residents, the medical record and immunization record failed to show documentation that they were offered or received another dose of the COVID-19 vaccine after those dates, in accordance with CDC recommendations and the facility’s policy. During interview and record review, the IP verified the missing documentation and stated he would contact the residents and/or responsible parties to offer and obtain consent, then document whether the vaccine was received or refused.
Staff Training and Competency Deficiencies
Penalty
Summary
The facility failed to maintain an effective training program for existing staff. Resident 1 had an order for oxygen via tracheostomy collar at 5 LPM, with care plan interventions for oxygen administration related to altered respiratory status, tracheostomy, CHF, and chronic respiratory failure. During observation, the SSD was seen in Resident 1's room turning the resident's oxygen concentrator off and on because it was beeping. The SSD stated he had no training specific to managing the oxygen concentrator, acknowledged he should have contacted the nurse, and the DON stated this action was not within the SSD's scope of practice. The DSD also stated the facility did not train the SSD to operate or troubleshoot residents' oxygen delivery equipment. The facility also failed to complete LVN 3's annual skill competency assessment. The annual competency form dated 3/18/24 did not document assessment method, date, or educator initials for multiple required competencies, including communication, compliance and ethics, safety and emergency procedures, person-centered care, cultural competency, precautions and PPE, infection reporting, behavioral health topics, documentation, pain management, alarms and restraints, and advance directives. In addition, in-service sign-in sheets for Problems and Needs of the Aged and Chronically Ill and Trauma-Informed Care showed signatures for the 7-3 and 3-11 shifts, but there was no documentation that staff on the 11-7 shift received those in-services. The DSD stated she had provided the in-service training for the 11-7 shift but could not produce documentation.
Inaccurate MDS Coding for Oxygen Use and Falls
Penalty
Summary
The facility failed to ensure that MDS assessments were coded accurately for two residents. For Resident 69, the medical record showed oxygen was administered at 2 lpm via nasal cannula on 7/13/25, and skilled evaluation notes on 7/14/25 and 7/15/25 also documented oxygen via nasal cannula. However, the admission MDS assessment was not coded to reflect that the resident received oxygen while a resident, even though the MDS instructions defined this as oxygen received at the facility within the last 14 days. During interview and concurrent record review, the MDS Coordinator stated the resident received oxygen during the look-back period and verified the MDS was coded incorrectly. For Resident 10, the eINTERACT Change in Condition Evaluation assessments documented falls on 3/22/25, 4/1/25, and 4/3/25, for a total of three falls. The discharge MDS assessment, however, showed only one fall since the previous MDS assessment. Review of the prior MDS showed it had been completed on 3/6/25. During interview and concurrent record review, the MDS Coordinator reviewed the record and stated the resident had three falls during the look-back period before the MDS assessment was completed, and verified the assessment was coded incorrectly.
Care Plans Not Revised After IV Therapy and Quetiapine Ended
Penalty
Summary
The facility failed to revise and resolve care plans for two sampled residents after the related treatments and medications were completed or discontinued. Resident 10 had a care plan focus initiated on 6/12/25 for IV therapy and IV antibiotics for a UTI, but the order summary did not show current physician orders for the IV therapy or IV antibiotics, and the DON stated during interview on 8/7/25 that the IV therapy and antibiotics had been completed in June 2025 and the care plan should have been revised and resolved when they ended. Resident 69 had a care plan focus initiated on 7/22/25 for quetiapine, but the order summary did not show current physician orders for the medication, and the DON stated during interview on 8/7/25 that quetiapine was discontinued on 8/1/25 and the care plan should have been revised and resolved when the medication was discontinued.
Inaccurate medical record documentation for assessments and PRN narcotic administration
Penalty
Summary
The facility failed to ensure that resident medical records were accurate for Resident 79, Resident 59, and Resident 32. For Resident 79, the chart showed a temperature and pain level were documented on a date after the resident had already expired. The closed record review showed Resident 79 was found not breathing, had absent breath sounds and a carotid pulse, and was pronounced dead at 0738 hours, yet later documentation in the temperature and pain summaries recorded that those assessments were obtained and entered at 1243 hours. The DON reviewed the record and verified that the entries were inaccurate because Resident 79 was not alive at the time the assessments were documented. The facility also failed to accurately document PRN narcotic pain medication administration for two residents. For Resident 59, the controlled drug record showed oxycodone 10 mg was removed, but the MAR documented that oxycodone 5 mg was administered instead. For Resident 32, the controlled drug record showed hydrocodone-acetaminophen 5-325 mg one tablet was removed, but the MAR documented that a half tablet was administered instead. During interview, the DON stated the nurses reported giving the doses removed from the controlled drug records, but the MAR entries were incorrectly documented. The Administrator, DON, and Nurse Consultant were informed of these findings.
Resident Rooms Did Not Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure 16 resident rooms measured at least the minimum required 80 square feet per resident. Review of the facility's Client (Resident) Accommodations Analysis form, which was undated, showed that Rooms 1, 3, 5, 6, 7, 9, 11, 12, 14, 15, 17, 18, 19, 20, 21, and 23 measured less than the required minimum square footage per resident. During an interview and concurrent document review with the Administrator on 8/6/25 at 1320 hours, the Administrator verified that these 16 resident rooms did not meet the minimum required 80 square feet per resident.
Failure to Implement and Communicate Care Plan Interventions for Suspected Financial Abuse
Penalty
Summary
The facility failed to implement and communicate comprehensive care plan interventions for a resident with a suspected allegation of financial abuse. According to the facility's policies and procedures, the care plan should be reviewed and revised upon a resident's status change, including incidents of suspected abuse. The care plan for the resident included interventions such as assuring the resident's safety, providing emotional support, establishing visitation guidelines, and monitoring for signs of distress. However, these interventions were not effectively implemented or communicated to all staff involved in the resident's care. Interviews with facility staff revealed that the social services director (SSD) did not assess or monitor the resident regarding the suspected financial abuse, despite being aware of the situation. Certified nursing assistants (CNAs) and licensed vocational nurses (LVNs) were not informed of the allegation or instructed to provide additional monitoring during visits from the alleged perpetrator. The visitor log confirmed that the family member accused of financial abuse continued to visit the resident multiple times after the allegation was reported, without increased supervision or monitoring as outlined in the care plan. Further review and interviews with the director of nursing (DON) and the administrator confirmed that required assessments, documentation of change in condition, post-incident monitoring, and social services assessments were not completed. The care plan interventions were not updated or implemented, and there was a lack of communication to staff regarding the necessary protective measures. This failure had the potential to leave the resident unprotected and without appropriate care and services to meet their needs following the suspected abuse.
Incomplete Dialysis Communication Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the Dialysis Communication Forms were properly completed for two residents receiving hemodialysis. For both residents, licensed staff did not document required pre- and post-dialysis information, including the status of dialysis access sites and the general condition of the residents upon return from the dialysis center. Medical record reviews showed multiple instances where sections of the Dialysis Communication Forms were left blank, such as shunt location/status, medications administered prior to dialysis, catheter status, and general condition post-dialysis. These omissions were in direct contradiction to the facility's own policies and procedures, which require thorough monitoring and documentation before and after dialysis treatments. Both residents had physician orders for regular hemodialysis and specific instructions to monitor their access sites every shift. Despite these orders, the required documentation was not completed on several dates. During interviews, both the RN and DON acknowledged the importance of conducting and documenting pre- and post-dialysis assessments to ensure appropriate care and timely interventions. The lack of completed documentation meant that the medical records for these residents were incomplete, as confirmed by the facility staff.
Failure to Provide Bed Hold and Notification
Penalty
Summary
The facility failed to ensure that a resident was provided a bed hold for up to seven days when the resident returned to a different room and bed upon readmission. The resident, who had severe cognitive impairment as indicated by a BIMS score of two, was initially admitted to the facility and later transferred to an acute care hospital. Upon readmission, the resident was placed in a different room despite the facility having available beds in the original room. The Director of Nursing (DON) and RN Consultant were unable to provide an explanation for this decision. Additionally, the facility did not provide the resident or the resident's representative with a written bed hold policy upon transfer to the hospital. The facility's policy requires that residents and their representatives be informed of the bed hold policy prior to transfer, but a review of the resident's medical record showed no evidence that this information was provided. The DON and RN Consultant confirmed that no bed hold information was given before the transfer, and the Administrator acknowledged these findings.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement effective infection control practices, resulting in a deficiency related to the improper cohorting of residents and inadequate use of personal protective equipment (PPE). Resident 2, who was diagnosed with salmonella and placed on contact isolation precautions, was inappropriately cohorted with Resident 1, who did not have salmonella. Both residents were dependent on staff for care and shared a bathroom, increasing the risk of contamination for Resident 1. Interviews with LVN 1, RN 1, and the Director of Nursing (DON) confirmed that Resident 1 should not have been cohorted with Resident 2 due to the high risk of contamination. Additionally, the facility's staff failed to adhere to standard precautions and PPE protocols. RN 1 was observed not performing hand hygiene and not wearing gloves or a gown while providing care to Resident 2, who was under contact isolation precautions. This was verified by RN 1, who acknowledged the importance of following proper infection control measures. Furthermore, a visitor was observed sitting on Resident 2's bed without wearing gloves or a gown, and Caregiver 1 was seen feeding Resident 1 without wearing a gown, despite being in a contact precaution room. Caregiver 1 admitted to not receiving training or education regarding contact precautions. The facility's policies and procedures for transmission-based and standard precautions were not effectively implemented, as evidenced by the observations and interviews conducted. The failure to follow these protocols compromised the safety and sanitary environment of the facility, increasing the risk of disease transmission among residents, staff, and visitors. The Administrator, DON, and RN Consultant were informed of these findings, acknowledging the lapses in infection control practices.
Failure to Monitor and Notify Physician of Resident's Wound and Skin Breakdown
Penalty
Summary
The facility failed to provide necessary care and services for a resident, identified as Resident 3, by not monitoring the resident's wound separation on the forehead and skin breakdown on the left and right arms every shift as ordered by the physician. The resident had an unwitnessed fall resulting in a forehead laceration, and there were physician orders to monitor these areas every shift. However, the Treatment Administration Record (TAR) for November 2024 showed that several shifts left the monitoring sections blank, indicating that the assessments were not conducted as required. Additionally, the facility did not notify the physician of changes in the resident's condition, as indicated by the documentation of 'Y' in the TAR, which signified skin breakdown. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the physician should have been notified of the skin breakdown, but there was no documented evidence of such notifications. The DON also verified the failure to monitor the resident's condition on specific dates, and there was no documentation explaining why the monitoring was not performed.
Failure to Evaluate Resident for Thickened Liquids
Penalty
Summary
The facility failed to ensure that a speech therapist (ST) evaluated a resident who had an order for thickened liquids, as per the facility's policies and procedures (P&P). The resident, who lacked the capacity to understand and make decisions, was admitted with orders for a regular diet with nectar consistency liquids and aspiration precautions. However, the resident's plan of care did not include a care plan for nectar thick consistency beverages, and there was no documentation of an evaluation by the ST. Interviews with the registered dietitian (RD) and registered nurses (RNs) revealed that the RD did not perform a functional ability evaluation and expected the ST to follow up for evaluation of liquid consistency. The RNs confirmed that the need for modified thickened liquids was not addressed in the resident's plan of care. The ST acknowledged that she had not evaluated the resident's swallowing function or the appropriate liquid consistency, which was part of her assessment responsibilities.
Failure to Assess Residents' Ability to Handle Hot Liquids
Penalty
Summary
The facility failed to ensure that five sampled residents were free from accident hazards related to the consumption of hot beverages. The facility's policy and procedure (P&P) for hot liquid safety required an assessment of residents' ability to handle containers and consume hot liquids, with individualized interventions noted on the care plan. However, the facility did not conduct these assessments for the residents involved, leading to incidents where residents were injured by hot liquids. Resident 1, who had severe cognitive impairment and required assistance for eating, spilled hot chocolate on her chest, resulting in second-degree burns. The incident occurred because the resident was not assessed for her ability to handle hot liquids, and the staff member, CNA 5, provided the hot chocolate without consulting a nurse. Similarly, Resident 2, who also had severe cognitive impairment, spilled coffee on himself. The facility's records showed no evidence of an assessment for his ability to handle hot liquids, and staff interviews confirmed that such assessments were not routinely performed. Residents 3, 4, and 5, who had varying levels of cognitive function, were also not assessed for their ability to handle hot liquids, as required by the facility's P&P. Interviews with staff, including the Rehab Director and RN 2, revealed that the facility did not perform specific assessments for handling hot liquids, despite the policy's requirements. The Director of Nursing (DON) acknowledged the lack of assessments for these residents, indicating a systemic issue in adhering to the facility's safety protocols.
Failure to Provide Properly Thickened Liquids
Penalty
Summary
The facility failed to ensure that food and beverages were prepared in a form to meet the individual needs of Resident 2, who required thickened liquids to prevent aspiration. Despite having orders for nectar-thick consistency liquids, Resident 2 was observed consuming regular consistency coffee on multiple occasions. Interviews with various CNAs revealed a lack of knowledge and consistency in preparing thickened liquids, with some staff unsure of the correct amount of thickener to use or the proper method of preparation. The facility's policy and procedure for serving meals indicated that diets should be served according to physician orders, and thickened liquids should be provided by the dietary department. However, the Assistant Dietary Manager confirmed that the responsibility for preparing thickened beverages fell on the CNAs and nurses, who were not adequately trained. The CNAs and nurses expressed confusion about the correct measurements and methods for preparing nectar, honey, or pudding-thickened beverages, with some relying on estimations or incomplete instructions. Further investigation revealed that the facility's in-service training did not adequately cover the preparation of thickened liquids. The Director of Nursing acknowledged that the plan of care for Resident 2 did not reflect the need for thickened liquids, and the in-service training materials provided did not include instructions on the proper preparation of thickened beverages. This lack of training and oversight placed Resident 2 at risk for aspiration, as the staff was not equipped to meet the resident's dietary needs.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to report and investigate an allegation of staff-to-resident abuse involving a resident who felt intimidated by the care provided by a CNA. The resident's family informed the facility's Director of Nursing (DON) about the resident's feelings of intimidation, which should have been considered an allegation of abuse according to the facility's Abuse, Neglect, and Exploitation Policy and Procedure (P&P). Despite this, the DON did not recognize the situation as an abuse allegation and did not report it to the State Agency as required. The facility's Administrator was aware of the allegation but confirmed that the facility did not report the incident to the State Agency or conduct an investigation. The facility's P&P mandates that such allegations be reported immediately, but not later than two hours after the allegation is made, and that a thorough investigation be conducted with results reported to the State Agency within five working days. The failure to follow these procedures resulted in the State Agency not being notified, which posed a risk to resident safety.
Improper Transfer/Discharge of Resident
Penalty
Summary
The facility failed to ensure a resident's right to remain in the facility was upheld, resulting in an improper transfer/discharge process. The incident involved a resident who exceeded her out-on-pass time and missed scheduled medications. Upon her return, the facility did not allow her to re-enter, failed to notify her physician, and did not conduct an assessment. The facility also did not coordinate a transition of care with a receiving facility or provide necessary information to the resident or her family for a safe transition. The resident's family member had to transport her to an acute care hospital emergency department, where she waited for hours. During this time, the resident experienced elevated blood pressure and low oxygen saturation levels, along with mild abdominal pain. The facility's actions led to the resident being labeled as discharged against medical advice (AMA) without proper documentation or communication with the resident's physician. Interviews with facility staff, including the social worker and physician, revealed a lack of communication and adherence to the facility's policies and procedures regarding transfers and discharges. The facility did not provide the resident or her family with a written transfer/discharge notice, appeal rights, or information necessary for a safe transition. The facility's administrator acknowledged that the resident did not meet any exemptions for a facility-initiated transfer/discharge and that the physician should have been notified of the resident's return.
Failure to Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a notice of transfer or discharge to a resident and the resident's representative before initiating a transfer or discharge. This deficiency was identified during a review of the facility's policies and procedures (P&P) and the medical record of a resident who was discharged against medical advice (DC AMA). The facility's P&P, revised on 12/19/22, requires that a transfer/discharge notice be provided to the resident and their representative in a language and manner they can understand, including specific details such as the reason for the transfer, the effective date, the new location, and the resident's right to appeal. However, the facility did not provide this notice to the resident or their family member, which could have affected their ability to appeal the decision. The incident involved a resident who had the capacity to understand and make decisions, as noted in their history and physical examination. The resident had a physician's order allowing them to be out on pass for four hours, but upon returning late, the social worker informed the resident and their family member that the resident could not re-enter the facility due to a DC AMA order. The social worker did not provide the required written notice or coordinate the transfer with a receiving provider or transportation company. The facility administrator confirmed that the facility failed to adhere to its P&P by not providing the necessary transfer/discharge notice, which would have included information on appeal rights and contact details for the state ombudsman.
Inadequate Pain and Skin Care Assessment
Penalty
Summary
The facility failed to provide adequate care and services for a resident's pain and skin condition. The resident complained of pain, but the pain was not comprehensively assessed for key characteristics such as location, timing, frequency, and duration. Non-pharmacological interventions were not offered before administering pain medication, and the resident was given medication prescribed for severe pain despite reporting moderate pain. The physician was not informed of the resident's moderate pain level, and there was a lack of documentation regarding the pain assessment and interventions. The resident was admitted with multiple skin issues, but the skin was not comprehensively assessed. The assessment lacked documentation of the size, location, drainage, pain, odor, type of tissue in the wound bed, and extent of redness and skin discoloration. Despite having physician's orders for wound care, the skin assessment was incomplete, and there was no documentation of the resident's refusal to be assessed or the reason for refusal. The care plan to address the resident's skin issues was also missing. Interviews with facility staff revealed that the necessary documentation and communication regarding the resident's pain and skin condition were not completed. The Quality Assurance staff acknowledged the need for a physician's order for moderate pain medication, and the Infection Preventionist confirmed the lack of documentation for the care plan. The failure to document and communicate effectively had the potential to impact the resident's care needs.
Failure to Assist Resident with Toileting Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure that Resident 5 remained free from accident hazards, resulting in the resident sustaining a fracture to the right humerus and requiring hospitalization. Resident 5, who had impaired cognition and was at risk for falls due to gait and balance problems, informed a CNA that she needed to use the bathroom. However, the CNA did not assist her and instead notified the CNA Team Lead to inform the assigned CNA. The assigned CNA was not informed, and Resident 5 attempted to transfer herself to the toilet, leading to a fall. Resident 5 had a history of falls and required assistance with toileting due to impaired mobility and being chair-bound. The facility's policies required adequate supervision and assistance to prevent falls, but these were not followed. The CNA Team Lead used the facility's paging system to request assistance for Resident 5 but did not follow up to ensure the request was fulfilled. Consequently, Resident 5 was left unattended and attempted to use the bathroom on her own, resulting in a fall. Interviews with the CNAs and LVN involved revealed a lack of communication and follow-up regarding Resident 5's need for assistance. The CNAs were occupied with other tasks and did not ensure that Resident 5 received the necessary help. The facility's investigative report confirmed that Resident 5 attempted to use the restroom independently and lost balance, leading to the injury.
Failure to Document Indwelling Urinary Catheter Care
Penalty
Summary
The facility failed to provide necessary care and services for indwelling urinary catheter care for one resident, identified as Resident 4. The facility's policy and procedure (P&P) for catheter care, dated 12/19/22, required catheter care to be performed every shift and as needed. However, the medical record review revealed that the catheter care documentation was missing for Resident 4 on several occasions, specifically on 9/9, 9/10, and 9/14/24. The Treatment Administration Record (TAR) for September 2024 also lacked documented evidence that the indwelling urinary catheter care was performed every shift, despite the presence of other treatments being documented. Interviews with LVN 3 and the Infection Preventionist confirmed the lack of documentation and assessment for the indwelling urinary catheter care. LVN 3 admitted to performing the catheter care but failing to document it, and acknowledged that the care should be given every shift. Additionally, LVN 3 was unable to provide documentation for the care plan addressing the use of the indwelling urinary catheter. The Infection Preventionist also could not provide the necessary documentation for the care plan, verifying the findings of the deficiency.
Failure to Notify Family of Resident's Belongings
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the management of a resident's personal belongings, specifically for Resident 4. The policy required that an inventory of the resident's personal items be reviewed and examined by a social services designee and the resident's representative. Additionally, upon a resident's discharge or death, the recipient of the personal items should sign a legal acknowledgment of receipt. In the case of a deceased resident, the facility was to notify the family or responsible agent via certified letter, including a copy of the inventory and options for disposition of the belongings. However, the review of Resident 4's closed medical record revealed that the inventory list was still in the record, and there was no documented evidence that the family was informed about the belongings or offered methods for their disposition. Interviews with facility staff confirmed the oversight. The Social Worker admitted to not following up with Resident 4's family regarding the personal belongings. Furthermore, the Director of Medical Record acknowledged that a copy of the inventory list should have been provided to the resident's representative or family member. This lapse in communication and procedure had the potential to affect the ability of the resident's family to be informed about the resident's belongings, as the facility did not follow its established protocol.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for a resident, identified as Resident C. During an observation on 9/18/24, the frame of Resident C's bedside commode was found to be rusty and corrosive. Resident C expressed discomfort with the condition of the commode and mentioned having informed the staff about it, but it had not been replaced. An interview with the Director of Nursing (DON) confirmed awareness of the issue, and the DON stated that maintenance would be informed to replace the commode. However, by 9/23/24, the commode had still not been replaced, as verified by the Director of Staff Development (DSD) during an interview with Resident C.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to comply with the required room size standards, as it did not obtain the necessary waivers for rooms that did not meet the minimum square footage requirements. During an observation and document review, it was found that multiple rooms were below the required 80 square feet per resident in multi-patient rooms. Although a waiver for room variance was approved in 2019 for several rooms, no waivers were obtained for 2023 and 2024. The Administrator confirmed the lack of current waivers and acknowledged not being aware of the need for them, as there was no handover from the previous administrator. The Maintenance Director also verified the non-compliance of 16 rooms with the required square footage.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, posing a risk of foodborne illnesses to 75 residents who consumed food prepared in the kitchen. During an inspection, it was observed that kitchen equipment was not air-dried before storage, as required by the facility's policy. Specifically, two clear containers and two metal pans were stored wet. Additionally, two white cutting boards were found to be heavily marred with knife marks and frayed laminate material, making them difficult to clean and sanitize, which is against USDA Food Code standards. Further deficiencies were noted in the thawing process for meats, where a container of completely thawed bacon was found in the walk-in refrigerator without being documented in the Thawing Log. This oversight was confirmed by the Dietary Supervisor. Additionally, the ice machine's splash guard and the outside left area were not clean, with black residue and white hard residue observed. These findings were verified by the Treatment Nurse and Maintenance Supervisor, indicating a lack of adherence to the facility's Ice Machine Cleaning Procedures.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that it was safe for three residents to self-administer medications, as required by their policy and procedure. Resident 59 was found with a bottle of Lung Cleansing Spray at her bedside without a physician's order, assessment, or care plan for self-administration. Despite being cognitively intact and having the capacity to make decisions, there was no documentation supporting her ability to self-administer the medication safely. The resident admitted to purchasing the medication online and using it independently. Resident 72, who had moderate cognitive impairment, was observed with hydrocortisone cream and Pain-A-[NAME] cream at her bedside. Similar to Resident 59, there were no physician's orders, assessments, or care plans in place for her self-administration of these medications. The resident stated that her family brought the medication, and she applied it herself. The lack of documentation and assessment raised concerns about her ability to manage her medications safely. Resident 9 was found with antifungal powder at her bedside, which she claimed to have purchased online and used independently. Although she had the capacity to understand and make decisions, there was no physician's order, assessment, or care plan for her self-administration of the medication. The facility's interdisciplinary team had not evaluated her ability to self-administer medications safely, as required by the facility's policy. Interviews with staff confirmed the absence of necessary documentation and assessments for all three residents.
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What surveyors actually found near you
We read the 6,437 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near La Habra
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Regency Care Center | 0 mi | ★★★★★ | 23 | 0 |
| Whittier Hills Health Care Ctr | 1.3 mi | ★★★★★ | 35 | 0 |
| St Elizabeth Healthcare Center | 2.7 mi | ★★★★★ | 25 | 0 |
| Imperial Healthcare Center | 2.9 mi | ★★★★★ | 1 | 0 |
| The Pavilion At Sunny Hills | 3 mi | ★★★★★ | 9 | 0 |
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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.