Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookside Healthcare Center during CMS and state inspections, most recent first.
Medication destruction logs showed 163 non-controlled meds were destroyed with only one licensed nurse signature and 20 were destroyed with no licensed nurse signature. The ADON confirmed the facility's practice was to have one nurse dispose of the meds and sign the log, even though the facility P&P required two authorized witnesses, and the Admin and ADON acknowledged the policy was not followed.
Failure to complete a new PASRR Level I screening and referral after a resident developed psychosis and bipolar disorder. The resident had been admitted with multiple medical diagnoses, and an initial PASRR Level I was negative at admission. Later EMR review showed new mental health diagnoses, but there was no documentation of a repeat PASRR Level I, PASRR Level II, or referral for review; the MDS nurse and Administrator confirmed the required PASRR documentation was missing and that the facility did not follow its PASRR policy.
A resident with Type 2 DM, ischemic cardiomyopathy, and HTN received 7 units of NovoLog after a blood glucose check showed 128, but the rapid-acting insulin was given about 1 hour and 25 minutes before breakfast. The LVN acknowledged that insulin should be administered close to meal time, and the Admin and ADON stated the physician order and medication administration policy were not followed.
Kitchen sanitation deficiencies were identified when chipped paint was observed in the dry storage room near stored food and a cutting board used for resident meal preparation was found worn, scored, chipped, and discolored. The DS confirmed the paint issue, and the DC and RD confirmed the cutting board was not in acceptable condition and needed replacement. The facility policy required counters, shelves, and equipment to be maintained in good repair and free from chipped areas.
A soiled utility cart was found inside a resident’s room during direct care, next to the privacy curtain and past the doorway threshold. The ADON, DSD, IP, and CNA all confirmed the cart should remain outside resident rooms because it contained trash and dirty linens from multiple residents, and the CNA stated it may have rolled into the room while care was being provided. The resident had diagnoses including femur fracture status post hemiarthroplasty and COPD with lower respiratory infection.
A facility failed to keep call lights within reach for two residents. One resident with hemiplegia, parkinsonism, and repeated falls had the call light on the floor beside the bed, and another resident with hemiplegia, aphasia, and cognitive communication deficit had the call light wrapped around the bed rail behind him with the button facing the floor. An LVN confirmed both call lights were unreachable, and the ADON acknowledged the facility policy requiring the call device to be placed within the resident’s reach was not followed.
The facility failed to maintain food service safety standards, as observed during a survey. Food crumbs, grime, and trash were found under the steam table, and food crumbs and thickener powder residue were present in the preparation area. Additionally, six wet scoops were improperly stored, which could lead to bacterial growth. These deficiencies had the potential to expose residents to foodborne illnesses.
The facility failed to implement proper infection control measures, including not changing a resident's oxygen tubing as per policy, allowing an LPN with COVID-19 symptoms to work without testing, and multiple staff not performing hand hygiene at critical times. These actions risked cross-contamination and infection spread among residents, staff, and visitors.
A facility failed to maintain accurate documentation in a resident's Treatment Administration Record and had incomplete POLST forms for three residents. The TAR showed gaps in catheter care documentation, while the POLST forms lacked essential information like physician signatures and advance directives. Staff acknowledged these omissions, which could lead to miscommunication and care delays.
A resident readmitted to the facility with multiple medical conditions, including end-stage renal disease and recent amputation, did not have a care plan developed to address their high risk for nutritional deficit. Observations noted the resident appeared pale and weak, with untouched food, and interviews confirmed the absence of a care plan despite facility policy requiring one within 24 hours of admission.
A facility failed to create an individualized care plan for a resident with ongoing constipation issues. Despite the resident's cognitive intactness and a documented history of constipation, no care plan was developed to address this condition. The resident reported ongoing constipation problems, and a review confirmed the absence of a specific care plan, contrary to facility policy.
A resident with moderate cognitive impairment was not provided with an individualized activity program that met their preferences for music, news, and outdoor time. Despite these preferences being documented, observations showed the resident often remained in their room without appropriate activities. The activity log indicated infrequent one-on-one activities, and the Activity Director confirmed a lack of documentation regarding the resident's participation or refusal.
A resident admitted for hospice care did not have a hospice plan of care available to facility staff, leading to potential delays in treatment and uncoordinated care. The resident, with multiple medical conditions, was admitted to hospice care, but the plan of care was not provided within the expected timeframe. This oversight was confirmed through staff interviews and record reviews, highlighting a lapse in communication between the hospice agency and the facility.
Two residents in an LTC facility did not receive oxygen therapy as prescribed by their physicians, with one receiving 2.5 LPM instead of the ordered 3 LPM, and another receiving 2.5 LPM instead of 2 LPM. The discrepancies were confirmed by nursing staff, who acknowledged the importance of following physician orders to prevent respiratory distress. Both residents had significant medical histories requiring precise oxygen management.
An LVN failed to demonstrate competency in administering medication through a G-tube for a resident with dysphagia. The LVN pushed Pantoprazole through the G-tube with a syringe instead of allowing it to flow by gravity, as per facility policy. This action was contrary to the prescribed method and acknowledged by the DON.
A facility failed to ensure follow-up on a hospice evaluation order for a resident with dementia, stroke, aphasia, and major depressive disorder. Despite a physician's order and family agreement, there was no documentation of Social Services contacting a hospice company or the family. The absence of follow-up was confirmed by the Case Manager and Social Services Director, and the DON acknowledged the oversight.
A resident's antibiotic regimen was not properly monitored for adverse reactions, and the indication for use was unclear. The facility did not document the required monitoring for adverse reactions or initiate infection surveillance. The resident, with a complex medical history, was prescribed Amoxicillin-Pot Clavulanate without specifying the infection site, contrary to the Physician Discharge Summary's recommendation for a respiratory infection.
A resident admitted with multiple fractures, interstitial pulmonary disease, and depression did not receive a history and physical exam (H&P) within the required timeframe. The facility's policy and state regulations mandate an H&P within 72 hours of admission, but it was completed six days later. The DON confirmed this delay could impact the resident's care.
A resident admitted with a left trochanter wound did not receive timely wound measurements as required by the facility's policy. Despite the resident's medical history, including diabetes and hypertension, the initial assessment and subsequent evaluations failed to document wound measurements until four days post-admission. Interviews with staff confirmed the oversight, highlighting a lapse in following wound management protocols.
A long-term care facility failed to respond to call lights in a timely manner, as reported by three residents with significant medical conditions. These residents experienced delays of up to 3 hours, particularly during the night shift, which contradicted the facility's policy of answering call lights within a reasonable time. The DON was unaware of any complaints, despite the residents' reports.
Medication Destruction Logs Lacked Required Witness Signatures
Penalty
Summary
The facility failed to ensure that discontinued, expired, or no longer needed medications were destroyed in accordance with its policy and regulatory requirements for non-controlled medications. During interview and record review, the Non-Controlled Medication Disposition Logs for the facility were reviewed and showed that 163 medications were documented as destroyed with only one licensed nurse signature, and an additional 20 medications were documented as destroyed without any licensed nurse signature on the logs. The Assistant Director of Nursing verified that the logs contained only one licensed nurse signature and confirmed that the facility's current practice did not require two licensed nurses to witness and sign for destruction of non-controlled medications. The Administrator and ADON also reviewed the facility's 2023 policy titled, Disposal of Medications, which stated that non-controlled substances in California were to be destroyed in the presence of either a pharmacist and a licensed nurse, two licensed nurses, or an administrator and a licensed nurse, and that the medication disposition log was to contain two witness signatures. Both acknowledged that the facility's policy was not followed.
Failure to Complete PASRR Review After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a new PASRR Level I screening was completed and a referral made for further PASRR review after a resident was diagnosed with unspecified psychosis and later bipolar disorder. The resident was admitted with diagnoses including right-sided hemiplegia, muscle weakness, difficulty walking, aphasia, syncope and collapse, hyperlipidemia, stimulant abuse, hypertension, malaise, and cerebral infarction without residual deficits. A PASRR Level I screening dated April 8, 2020, had been negative at admission and did not recommend further evaluation. A review of the resident’s EMR showed diagnoses of unspecified psychosis not due to a substance or known physiological condition with an onset date of May 8, 2020, and bipolar disorder, unspecified, with an onset date of March 1, 2023. The record contained no documentation of a new PASRR Level I screening, no PASRR Level II evaluation, and no referral to the appropriate PASRR entity after these diagnoses were added. During interview, the MDS Nurse could not locate the required PASRR documentation and confirmed it was not present in the EMR, and the Administrator acknowledged the facility did not follow its PASRR policy and that a PASRR review and referral should have been completed.
Insulin Given Too Early Before Meal
Penalty
Summary
The facility failed to ensure that a resident was free from a significant medication error when rapid-acting insulin was administered too early in relation to a meal. Resident 53 was admitted with diagnoses including Type 2 DM, ischemic cardiomyopathy, and hypertension. On June 17, 2026, at 5:50 AM, the resident’s blood glucose was checked and was 128. At 5:58 AM, LVN 4 administered 7 units of NovoLog insulin based on the sliding-scale order for blood glucose 120-180. The physician order directed that Aspart insulin be given subcutaneously before meals and at bedtime, and LVN 4 later acknowledged that rapid-acting insulin should be administered within a close timeframe to meal consumption, usually within thirty minutes, because giving it too early may place a resident at risk for hypoglycemia. During observation at 7:23 AM, the resident was seen receiving the breakfast tray approximately one hour and twenty-five minutes after the insulin was administered. During the concurrent review, LVN 4 agreed the insulin had been given too early in relation to the meal and that it should not have been administered at that time. The facility’s policy on administering medications stated that medications are to be accurately prepared, administered, and documented, and the Admin and ADON stated the physician order was not followed and the policy was not followed.
Kitchen Sanitation and Food Preparation Deficiencies
Penalty
Summary
Safe and sanitary food preparation and storage practices were not followed in the kitchen when chipped paint was observed on the wall in the dry storage room behind where food was stored. During the observation, the Dietary Supervisor confirmed the chipped paint was present and stated that chemicals from the paint can contaminate food. The facility policy for sanitation stated that counters and shelves shall be maintained in good repair and free from chipped areas. A cutting board used to prepare food for residents was observed in the kitchen to be worn, with scoring, areas of chipping, and visible discoloration. The Dietary Consultant confirmed the cutting board was in that condition and stated it should not be, and the Registered Dietician also confirmed it was time to replace it. The facility policy for sanitation stated that equipment shall be maintained in good repair and free from breaks, corrosions, open seams, cracks, and chipped areas.
Soiled Utility Cart Placed Inside Resident Room During Care
Penalty
Summary
The facility failed to ensure used and contaminated materials were handled in a manner that prevented the spread of infection when a soiled utility cart was found inside Resident 40’s room during direct care. During an observation on June 17, 2026 at 7:01 AM, the cart was positioned past the room threshold and adjacent to the privacy curtain around the resident’s bed while a CNA was providing care. The Assistant Director of Nursing confirmed at the time of observation that the cart was in the room and stated it must remain in the hallway because of infection control concerns related to its contents, which included trash and dirty linens collected from other rooms and residents. Resident 40’s face sheet showed diagnoses including fracture of unspecified part of neck of femur, status post hemiarthroplasty, and chronic obstructive pulmonary disease with lower respiratory infection. During interviews, the CNA stated she usually leaves the cart outside the resident’s room before providing care and acknowledged it may have inadvertently rolled into the room, stating that having the cart inside a resident’s room is a significant infection control issue. The Director of Staff Development and the Infection Preventionist both stated the dirty utility cart must be kept outside residents’ rooms to prevent cross-contamination. Record review of the facility’s Laundry - Linen, Soiled policy showed guidance for handling soiled linen and keeping soiled linen containers covered and in designated containers, and the ADON stated the policy did not include specific guidance on cart placement while staff provide care.
Call Lights Left Out of Residents’ Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents. Resident 36 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, parkinsonism, and repeated falls. During observation, Resident 36 was lying in bed awake, and the call light was found on the floor on the resident’s right side of the bed and unreachable. An LVN confirmed the call light was on the floor and not within reach, and the resident stated she could not access it and would likely have to yell for help if assistance was needed. Resident 41 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, aphasia, and cognitive communication deficit. During observation, Resident 41 was in bed awake, lying on his right side facing the door, and the call light was wrapped around the bed’s left upper side rail behind him with the button pointing toward the floor and unreachable. An LVN confirmed the call light was not within reach, and the resident indicated he could not reach it. The ADON reviewed the facility policy requiring the call device to be placed within the resident’s reach before leaving the room and acknowledged the policy was not followed for either resident.
Failure to Maintain Food Service Safety Standards
Penalty
Summary
The facility failed to maintain professional standards for food service safety, as observed during a survey. During an initial observation tour of the kitchen, food crumbs, black grime, and trash were found on the floor under the steam table. The Dietary Services Director (DSD) acknowledged that the kitchen areas should be kept clean and free of debris, but admitted that the dietary staff did not perform regular cleaning. The facility's policy and procedure for general cleaning indicated that floors must be mopped at least once per day, which was not adhered to. Additionally, food crumbs and thickener powder residue were found in the food preparation area. The DSD confirmed that these areas should be kept clean and free of residues, but again noted that regular cleaning was not conducted by the dietary staff. The facility's sanitation policy required all utensils, counters, shelves, and equipment to be kept clean, which was not followed. The Registered Dietitian (RD) also acknowledged that the cook preparation area should be kept clean. Furthermore, six wet scoops were found stored inside a plastic container box, which the DSD stated should have been air-dried before storage to prevent bacterial growth. The facility's sanitation policy required all items to be air-dried with no water droplets present. The RD confirmed that utensils should not be stored wet, as moisture can harbor bacteria. These deficiencies had the potential to expose 78 of 84 highly susceptible residents to foodborne illnesses due to cross-contamination.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control and prevention measures in several instances, leading to potential cross-contamination and infection spread among residents, staff, and visitors. One deficiency involved Resident 58, whose oxygen tubing was not changed according to the facility's policy, which mandates weekly replacement to prevent odor and dirt accumulation. The tubing was last changed on October 13, 2024, but should have been replaced by October 20, 2024. This oversight was confirmed by LVN 4 and the Infection Preventionist (IP), who acknowledged the importance of adhering to the policy for infection control purposes. Another significant deficiency occurred when LVN 5, who exhibited COVID-19 symptoms, was not tested upon returning to work and before providing care to residents. Despite having a sore throat and other symptoms, LVN 5 continued to work without a documented negative COVID-19 test result. The IP admitted to discarding the test results and failing to document them, which is against the facility's COVID-19 mitigation plan that requires symptomatic staff to be tested and results recorded. This lapse in protocol could have facilitated the spread of infection within the facility. Additionally, multiple staff members, including LVN 4, CNA 1, and RNA 1, failed to perform hand hygiene at critical times, such as before and after resident contact, after handling soiled linens, and when moving between care activities for different residents. These actions were observed during various instances, and staff acknowledged their failure to adhere to the facility's hand hygiene policy. The lack of proper hand hygiene practices, especially in rooms with Enhanced Barrier Precautions, posed a significant risk of cross-contamination and infection spread.
Deficiencies in Documentation and POLST Forms
Penalty
Summary
The facility failed to ensure complete, accurate, and consistent documentation in residents' clinical records, as observed in the Treatment Administration Record (TAR) of one resident and the POLST forms of three residents. Specifically, the TAR for one resident showed multiple gaps in documentation regarding catheter care, monitoring of catheter placement, and signs and symptoms of infection. These omissions were acknowledged by the Registered Nurse Supervisor, who stated that documentation should be completed immediately after care is provided. Additionally, the POLST forms for three residents were found to have missing information, including critical details such as the date the form was prepared, physician signatures, and advance directive information. The Licensed Vocational Nurse and Registered Nurse Supervisor confirmed these omissions, noting that the forms were not filled out completely as expected. The Social Service Director also acknowledged that the POLST forms were not thoroughly reviewed, which could lead to delays in treatment or miscommunication. Interviews with the Director of Nursing and other staff members highlighted the expectation for complete and accurate documentation as part of their job responsibilities. The facility's policies and procedures emphasize the importance of thorough documentation to ensure proper care and communication. However, the observed deficiencies in documentation and incomplete POLST forms indicate a failure to adhere to these standards, potentially impacting the coordination and delivery of care to the residents.
Failure to Develop Nutritional Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan addressing the nutritional needs of a resident upon readmission, which was necessary due to the resident's high risk for nutritional deficit. This deficiency was identified during an observation and interview with the resident, who appeared pale and weak, and had not eaten their lunch. The resident expressed that the food was unappetizing following a recent hospital stay. The resident's brother provided additional context, noting that the resident was undergoing dialysis three times a week and had recently undergone a below-the-knee amputation due to gangrene. A review of the resident's records revealed multiple medical diagnoses, including systemic lupus erythematosus, dysphagia, end-stage renal disease, and dependence on renal dialysis, all of which contributed to the resident's high risk for nutritional deficit. Despite these conditions, no care plan was developed to address the resident's nutritional status. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of a care plan and emphasized the importance of such a plan in preventing weight loss and monitoring the resident's nutritional status. The facility's policy required care plans to be initiated within 24 hours of admission based on identified problems and changes in medical condition, which was not adhered to in this case.
Failure to Develop Individualized Care Plan for Constipation
Penalty
Summary
The facility failed to develop an individualized care plan for a resident to address ongoing constipation issues. The resident, who was admitted to the facility with a history of constipation, was found to be cognitively intact according to the Minimum Data Set assessment. Despite the physician's documentation of constipation in the resident's History and Physical, and the prescription of a bowel regimen including medications like Senna, Colace, Miralax, Dulcolax, and Fleet Enema, there was no care plan developed to address this issue. During an interview, the resident reported having a bowel movement three days prior and expressed ongoing problems with constipation. A review of the resident's care plans revealed that while baseline and comprehensive care plans were developed, there was no documented evidence of a care plan specifically addressing constipation. A Licensed Vocational Nurse confirmed the absence of a care plan for constipation, despite the issue being present upon admission. The facility's policy requires care plans to be initiated within 24 hours of admission and completed within seven days, but this was not adhered to in this case.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to meet the needs and interests of a resident, identified as Resident 83, who was part of a sample of 21 residents. Resident 83, who had moderate cognitive impairment, expressed preferences for listening to music, keeping up with the news, and going outside for fresh air. Despite these preferences being documented in the resident's care plan, the facility did not consistently offer activities that aligned with these interests. Observations revealed that Resident 83 was often found awake in his room, staring at a turned-off TV, with no stereo or sensory stimulation present. Interviews with the resident and staff indicated that while the resident preferred staying in his room, he also expressed a desire to go outside and listen to music. The activity log for October showed that one-on-one activities were only offered three times during the month, with music being offered only once, and there was no documented evidence of the resident's preferences being consistently addressed during these visits. The Activity Director acknowledged that while activities were offered based on Resident 83's preferences, there was a lack of documentation regarding the resident's participation or refusal of activities. The facility's policy emphasized the importance of implementing a resident-centered activities program, yet the documentation and execution did not reflect the resident's stated preferences, leading to a deficiency in providing individualized care.
Lack of Hospice Plan of Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination and collaboration with a contracted hospice agency for a resident admitted for hospice care. During an initial observation, it was noted that the resident, who was receiving oxygen therapy, did not have a hospice plan of care available to the facility staff. This oversight was confirmed during interviews and record reviews with various staff members, including a Licensed Vocational Nurse and a Minimum Data Set Nurse, who both verified the absence of the hospice plan of care in the resident's hospice binder. The resident, identified as having multiple medical conditions including hemiplegia, hemiparesis, aphasia, and chronic embolism, was admitted to hospice care on October 18, 2024. However, the hospice plan of care, which is crucial for ensuring coordinated care, was not provided to the facility staff within the expected timeframe. The Social Service Director received the hospice plan of care only on October 24, 2024, several days after the resident's admission to hospice care, indicating a lapse in communication and documentation between the hospice agency and the facility. Interviews with the Hospice Director of Patient Care Services and the Director of Nursing revealed that the hospice plan of care should have been available within 48-72 hours of hospice admission. The absence of this plan was acknowledged as a failure by the hospice agency, which did not meet the expected standards of timely communication and documentation. This deficiency had the potential to cause delays in treatment and uncoordinated care for the resident, as the facility staff were not informed of the specific care and services required for the resident's condition.
Failure to Follow Prescribed Oxygen Therapy for Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice and the residents' plans of care for two residents. Resident 10 was observed receiving oxygen therapy at a rate of 2.5 LPM, despite a physician's order for 3 LPM to maintain oxygen saturation at or above 90%. This discrepancy was noted during multiple observations over several days. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) confirmed that the oxygen therapy order was not followed, acknowledging the importance of adhering to the physician's order to prevent compromising the resident's respiratory status. Similarly, Resident 36 was observed receiving oxygen at 2.5 LPM, contrary to the physician's order of 2 LPM. This was also confirmed by the LVN and RNS, who reiterated the necessity of following the prescribed oxygen therapy to ensure patient safety. The Director of Nursing (DON) emphasized the expectation for nurses to adhere to doctor's orders to avoid respiratory distress in residents. Both residents had specific medical histories that necessitated precise oxygen therapy management. Resident 10 had a history of hemiplegia, hemiparesis following a stroke, and other conditions, while Resident 36 had diagnoses including essential hypertension and non-Hodgkin's lymphoma. The facility's policies and procedures, as well as job descriptions for nursing staff, highlighted the importance of following physician orders and maintaining resident safety, which were not adhered to in these instances.
LVN Fails to Follow G-tube Medication Administration Procedure
Penalty
Summary
A Licensed Vocational Nurse (LVN 7) at the facility failed to demonstrate competency in medication administration for a resident with a Gastrostomy tube (G-tube). The resident, identified as Resident 62, was admitted with diagnoses including dysphagia and Gastrostomy status. During a medication pass, LVN 7 was observed administering Pantoprazole, a medication intended to reduce stomach acid, by pushing it through the G-tube with a syringe, contrary to the prescribed method. The facility's policy and procedure for enteral tube medication administration clearly stated that medications should be allowed to flow down the tube via gravity and not be pushed through. This was confirmed during an interview with the Director of Nursing (DON), who reviewed the resident's Order Summary Report and acknowledged that LVN 7 did not follow the correct procedure. The failure to adhere to the facility's medication administration policy had the potential to cause complications for Resident 62.
Failure to Follow Up on Hospice Evaluation Order
Penalty
Summary
The facility failed to ensure that the Social Services Department followed up on a physician's order for a hospice evaluation for a resident, identified as Resident 30. The resident, who was admitted on an unspecified date, had a history of dementia, stroke, aphasia, and major depressive disorder, and lacked the capacity to understand and make decisions. A hospice evaluation was ordered on July 8, 2024, and the resident's family was aware and agreeable to the physician's recommendation. However, the Progress Notes from July 8, 2024, to October 23, 2024, did not indicate any follow-up by Social Services with a hospice company or the resident's family regarding the evaluation. During a review of Resident 30's medical record on October 24, 2024, the Case Manager and Social Services Director confirmed the absence of documentation showing follow-up actions. The Director of Nursing later stated that Social Services should have communicated with the family and hospice company to follow up on the hospice order. The job description for the Social Worker, revised in 2016, included duties to refer residents and families to appropriate social service agencies when necessary, which was not fulfilled in this case.
Failure to Monitor and Clarify Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the administration of antibiotics. For one resident, adverse reactions to the antibiotic Amoxicillin-Pot Clavulanate were not monitored as required. The Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that there was no documentation of monitoring for adverse reactions, which should have been conducted every shift for three days. Additionally, infection surveillance was not initiated at the start of the antibiotic therapy, which is crucial for identifying signs and symptoms of infections and determining the appropriate treatment. Furthermore, the indication for the antibiotic medication was unclear and not clarified with the doctor. The resident's medical records indicated a prescription for Amoxicillin-Pot Clavulanate without specifying the site of the bacterial infection. The Physician Discharge Summary recommended a seven-day course of Augmentin for a respiratory bacterial infection, but this was not reflected in the medication order. The DON verified that the infection surveillance contained incorrect information and that the indication for the antibiotic therapy was incomplete. The resident involved had a complex medical history, including Systemic Lupus Erythematosus, Dysphagia, End Stage Renal Disease, and dependence on renal dialysis. The resident had recently undergone a below-the-knee amputation due to a gangrene infection and was readmitted to the facility. Despite these significant health issues, the facility did not adhere to its policy on antibiotic stewardship, which requires monitoring of antibiotic use and infection surveillance.
Delayed History and Physical Exam for Resident
Penalty
Summary
The facility failed to comply with state requirements when Physician 1 did not complete a history and physical exam (H&P) within the timeframe specified in the facility's policy for a resident. The resident, who was admitted with multiple fractures, interstitial pulmonary disease, and depression, did not receive the required H&P until six days after admission. This delay was contrary to the facility's policy, which mandates that an H&P be completed within 72 hours following admission. During an interview, the Director of Nursing (DON) confirmed that the physician's assessment, documented in the H&P, is crucial for determining a resident's comprehensive medical condition. The facility's policy and the California Code of Regulations both require that a physical examination be conducted within 72 hours of admission. The DON acknowledged that the delay in completing the H&P could prevent the resident from receiving appropriate care and services.
Failure to Measure Wound on Admission
Penalty
Summary
The facility failed to adhere to its policy for wound management for a resident who was admitted with a left trochanter wound. Upon admission, the resident had a history of a fracture of the right fibula, difficulty walking, diabetes type II, and hypertension. The initial assessment on March 9, 2024, noted an open area from a popped blister on the left hip, but no wound measurements were documented. Subsequent assessments on March 10 and March 13 also failed to document the necessary wound measurements until four days after admission. Interviews with the Treatment Nurse and the Registered Nurse revealed that the initial skin assessment should have included wound measurements, which were not performed as required. The Director of Nursing confirmed that the facility's policy mandates wound assessments, including measurements, within 24 hours of admission. The lack of timely wound measurements placed the resident's health and safety at risk, as the facility did not follow its established procedures for wound management.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely response to call lights, which is crucial for providing care and services to residents. This deficiency was identified through interviews and record reviews involving three residents. Resident 1, who was admitted with conditions such as hemiplegia, intracerebral hemorrhage, and aphasia, reported that the night shift often did not respond to call lights for 1 to 2 hours. Similarly, Resident 2, with diagnoses including a wedge compression fracture and quadriplegia, stated that call lights could take 1 to 3 hours to be answered, which they found unacceptable. Resident 3, suffering from conditions like traumatic subdural hemorrhage and chronic kidney disease, also experienced delays of up to 1 hour, particularly during the night shift. The Director of Nursing (DON) was interviewed and stated that there had been no complaints from residents or family members regarding call light response times. However, the facility's policy clearly mandates that call lights should be answered within a reasonable time to ensure effective communication between residents and nursing staff. The failure to meet this policy potentially placed the health and safety of clinically compromised residents at risk, as their needs were not met promptly.
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What surveyors actually found near you
We read the 670 citations issued within 25 miles in the last 12 months — including the 4 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Redlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Grove Post Acute | 0.7 mi | ★★★★★ | 2 | 0 |
| Redlands Healthcare Center | 0.7 mi | ★★★★★ | 6 | 0 |
| Redlands Community Hospital D/p Snf | 0.7 mi | ★★★★★ | 8 | 0 |
| Asistencia Villa Healthcare Center | 1.2 mi | ★★★★★ | 18 | 0 |
| Plymouth Village | 2.3 mi | ★★★★★ | 1 | 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 October 2026) and official state health department websites.