Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buena Park Nursing Center during CMS and state inspections, most recent first.
A resident with no capacity to make his own decisions sustained multiple superficial facial scratches during shower care when a CNA with long nails was trying to manage the resident’s trach while rinsing his head and face. Staff interviews and facility records confirmed the CNA knew her nails were not compliant with policy, and an LVN was also observed with long, apparently artificial nails despite prior nail hygiene inservice education.
A facility failed to ensure psychotropic medication use was properly monitored for two residents. One resident with dementia and no decision-making capacity had orders for Rexulti and venlafaxine, but the record did not show documented nonpharmacological interventions when repeated behavior episodes occurred. Another resident receiving buspirone and PRN lorazepam had ordered orthostatic BP checks, but the sitting and lying readings were recorded as identical, and staff confirmed the monitoring was inaccurate.
Improper LAL mattress settings were observed for two residents receiving skin and wound management. Both residents had no capacity to make decisions, one had a history of pressure ulcer and high risk for further skin breakdown, and each had a physician order for an LAL mattress with checks every shift. In both cases, staff verified the mattress pressure setting was at or above the 150-pound mark even though the residents weighed 128 pounds and 120 pounds, respectively.
Respiratory care deficiencies were identified for several residents receiving vent, O2, or nebulizer therapy. Staff did not document or follow the manufacturer’s cleaning instructions for ventilators used by three residents, one resident was found without ordered O2 and with tubing/cannula on the floor, another resident had no No Smoking/Oxygen in Use sign posted while on O2, one resident’s O2 concentrator made a motor-like noise that bothered the resident, and another resident’s nebulizer tubing was touching the floor.
A facility failed to follow a posted Korean lunch menu for residents on pureed diets. During observation, a cook liquified seaweed soup instead of preparing it to the IDDSI L4 recipe, did not puree roasted [NAME] listed on the menu, and pureed kimchi without a specific recipe; the RD later stated the puree recipes were not geared to Korean foods.
Food safety and sanitation practices were not followed in the kitchen and during meal service. A staff member had hair exposed outside the hairnet, ladles were stored above the 3-compartment sink, a CNA delivered a resident’s tray without LPN check, and a cook failed to perform hand hygiene after touching a trash can while preparing puree foods.
Policy for Outside Food Did Not Address Storage or Reheating: The facility’s policy prohibited residents from storing or reheating food brought in from outside sources. The ADON stated there was no resident refrigerator, and the RD said she was aware of the policy but was not involved in developing it. The DON confirmed that personal food from outside was not to be stored or reheated per the facility policy.
The facility failed to follow its infection control program, including inaccurate infection surveillance using McGeer's criteria, incomplete documentation of infection data, and improper Legionella water system monitoring. Staff were also observed handling a resident call light without disinfecting it, moving from one resident's room to another without hand hygiene after glove removal, and an LVN was observed with long artificial fingernails.
A resident with no capacity to make decisions was prescribed venlafaxine via G-tube for depression, and the record showed consent was obtained from the representative. However, the informed consent form did not include possible nonpharmacological approaches or other reasonable alternative treatments for the psychotropic medication, and RN verified the omission during record review.
Failure to Provide Medicare Non-Coverage Notice: A resident with no capacity to make medical decisions was scheduled to end Medicare Part A coverage and discharge from the facility, but the chart did not show that the required NOMNC form was provided to the resident and/or representative. The BOM could not locate the form in the chart, and the DON acknowledged the finding.
A resident with decision-making capacity reported that an LVN was rude and had an attitude when answering his call light and told him he was pressing it too much. The resident told an RN about the interaction, but the RN did not document it, and the concern was not handled through the facility’s grievance process as described by the DON and P&P.
A resident with severely impaired cognitive skills was observed wearing a left hand mitten for pulling at medical devices. The restraint assessment did not show least restrictive interventions were tried before the mitten was used, and the MAR lacked clear documentation of when the mitten was released, what care was provided during release, and when it was reapplied. Staff interviews confirmed the resident was being watched for grabbing tubing and that no prior least restrictive measures were attempted.
Inaccurate MDS Coding for Resident With Right-Sided ROM Impairment: A resident with a hx of stroke and right-sided weakness was observed not moving his right arm and reported inability to move his right arm and leg. OT and PT records documented impaired ROM on the right upper and lower extremities, but a later MDS incorrectly coded no impairment in both upper extremities and impairment in both lower extremities. The MDS Coordinator and DON acknowledged the coding error.
A resident with a hx of bipolar affective disorder had a PASRR Level II determination recommending psychology consultation and psychotherapy/counseling services, but the services were not completed. The MDS Coordinator stated no follow-up was made with PASRR staff regarding the resident’s hospital dx and the PASRR recommendations.
A resident with psychosis had an inaccurate level 1 PASRR that showed no serious mental illness and no psychotropic meds, even though the MDS listed psychotic disorder and later the record included trazodone for depression-related insomnia. The record also showed a level 2 PASRR decision that no eval was needed because there was no SMI and no functional limitation, despite later MDS findings of lower-extremity ROM limitations and increased ADL dependence. The MDS Coordinator, MDS Nurse, and DON acknowledged the PASRR inaccuracies and that a Resident Review should have been completed.
The facility failed to develop individualized care plan problems for two residents. One resident had a physician order for a Dexcom G7 CGM receiver for diabetes, but no care plan addressed the device. Another resident was nonverbal, had muscle weakness and hemiplegia, and had a peripheral IV in the right arm for IV vancomycin, but no care plan addressed the IV site. An RN verified both omissions, and the DON confirmed the missing care plan for the CGM device.
The facility failed to keep several care plans current for residents with ventilators, NPO status, IV hydration, and hand mittens. Care plan interventions did not reflect ventilator cleaning and disinfection per manufacturer guidance, a resident’s NPO status and IV hydration therapy, or least restrictive interventions when a mitten was released. RNs verified the discrepancies during record review, and the DON acknowledged the findings.
Failure to Follow Orders for Glucose Monitoring, Insulin Site Rotation, and Medication Hold Parameters. A resident with DM had a Dexcom G7 CGM at bedside, but staff did not have the probe attached and there was no physician order for skin checks, device monitoring, or a care plan. Another resident received repeated insulin injections in the same abdominal site over multiple MAR entries, and staff acknowledged injection sites were not rotated. A third resident with no decision-making capacity received metoprolol and digoxin despite ordered hold parameters for low BP and low pulse, and an LVN could not verify the meds were held as ordered.
A resident with stroke-related right-sided impairment and limited ROM did not receive restorative nursing services consistent with the physician order and therapy recommendations. RNA staff provided PROM to the resident's right upper extremity even though the order and OT discharge recommendation called for AROM, and the RNA did not follow up with therapy about the mismatch. The resident also requested a reduction in RNA frequency from five days per week to three days per week, but the record did not show that he was informed of the potential for ADL decline before the reduction was approved.
GT Feeding Care and Labeling Deficiencies: Two residents receiving enteral feedings had care issues identified during survey observations. One resident was observed with GT feeding infusing while the HOB was not elevated to at least 30 degrees, despite orders and staff acknowledgment that elevation should be maintained to reduce aspiration risk. Another resident’s water flush bag connected to the feeding pump was not labeled with the date and time it was started, and an LVN confirmed the omission.
IV therapy was not managed according to standards for two residents. One resident receiving IV vancomycin had an IV dressing with no date on it, and another resident receiving continuous IV hydration had IV tubing labeled for 72 hours only but it remained in use past the discard date. Staff confirmed the missing dressing date and the overdue tubing during observation and interview.
PRN pain management was not provided per the physician’s orders for a resident who lacked decision-making capacity. The MAR showed hydrocodone-acetaminophen was given outside the ordered pain-level parameters, and the record did not show documented nonpharmacological interventions or their effectiveness before repeated PRN doses. The LVN and DON acknowledged the missing documentation.
A resident with no decision-making capacity had an order for PRN hydrocodone-acetaminophen for severe pain. The controlled drug record showed the Norco was signed out, and an LPN verified it was pulled, but the MAR did not document that it was administered. The DON confirmed there was no MAR evidence of the dose being given and described the expected narcotic documentation process.
Improper Medication Storage, Labeling, and Disposal: Surveyors found oral meds stored in the same medication cart cubes as external-use products, including eye drops and transdermal patches, and two opened boxes of ipratropium-albuterol were missing opened dates. Surveyors also observed a nurse discard a resident’s vancomycin IV tubing, NS bag, and empty container into the resident’s personal trash can; the RN and ADON confirmed the improper disposal.
Pureed meal preparation for American and Korean menus was started too far in advance of lunch service, with some items prepared earlier in the morning and held refrigerated before serving. During tray line observation, staff were also unsure of the proper serving temperature for kimchi; a dietary aide initially said it should be served below 40 degrees Fahrenheit, while the DSD stated 48 degrees Fahrenheit was acceptable at room temperature.
Failure to provide ordered sippy cup for a resident needing adaptive drinking equipment. During a meal observation, an RNA assisted the resident with beverages using straws instead of the sippy cup listed on the meal ticket and supported by a physician order for meals per family request. An LVN verified the issue during the observation, and the DON later confirmed the record findings.
Missing Pharmacist Documentation for P&P Review: The facility failed to document the pharmacist's participation in the review of its P&P related to pharmaceutical services. The P&P review record did not show the pharmacist's attendance, and the DON stated the pharmacist should have signed the review, but the signature was not present and no sign-in sheet was provided to show participation.
A facility failed to keep several resident records accurate. An RN entered an incorrect nutrition risk score for one resident despite a low albumin level, a POLST did not reflect an advance directive for another resident, an LPN documented furosemide as given even though it was held for low BP, and an RN did not document an IV site condition even though the site was no longer patent and the resident had swelling and pain.
A resident receiving hospice had incomplete coordination documentation between the facility and hospice agency. The hospice calendar did not fully show scheduled hospice visits, the hospice POC listed aide services at a frequency that did not match the actual aide visits, and the hospice record lacked RN, aide, social worker, and licensed nurse progress notes for multiple visits. The DON stated the hospice binder was meant to coordinate care and that hospice staff notes and visit schedules should be kept current.
Failure to Apply McGeer's Criteria for Antibiotic Use: The facility failed to accurately determine whether multiple residents met criteria for a true infection before antimicrobial therapy was used. The IP verified that several residents received antibiotics even though their infections did not meet McGeer's criteria, including cases that were not marked as DNMC. For blood infections, the IP relied on constitutional signs such as fever, leukocytosis, acute mental status change, or acute functional decline, but could not provide the reference used and later stated the proper criteria were not used. One resident also had a respiratory infection without a completed Surveillance Data Collection Form to determine whether it met McGeer's criteria.
Nurse staffing information was not posted daily in a prominent, visible location accessible to residents and visitors. During observation, the Daily Nurse Staffing Information was found sideways between a vase and other paperwork at the SNF station, and it was not the current day’s posting. The DSD stated the RN supervisor was supposed to post the current staffing data but forgot.
A resident with a left hand mitten restraint ordered to prevent pulling out a GT had a care plan and facility policy requiring the mitten to be released every two hours for circulation, comfort, and exercise. Record review showed only shift-level monitoring of mitten placement, with no documentation that the mitten was released every two hours as care-planned. An RN confirmed the protocol to remove the mitten every two hours and assess circulation and skin, but acknowledged there was no corresponding order or documentation showing these checks were performed.
A resident with glaucoma and no decision-making capacity had multiple missed doses of ordered ophthalmic medications, including Refresh Plus, Timoptic, and Lumify. MAR review showed numerous administrations not given, some coded as held or to see progress notes without clear reasons, and others marked as awaiting pharmacy delivery or out of stock. Nursing documentation reflected calls to the pharmacy but did not show that the physician was notified of the repeated missed doses. During interviews, RN staff acknowledged that charge nurses were responsible for timely refill requests and that the physician should have been informed when medications were not administered as ordered.
A resident who lacked decision-making capacity experienced a fall, but staff did not update the care plan to address this incident. Review of the medical record and interviews with an RN and the DON confirmed that no care plan problem or intervention was developed for the fall, despite facility policy requiring care plan updates after such events.
Two residents did not receive necessary care and monitoring as required by physician recommendations and facility policy. One resident did not have a recommended medication initiated, did not receive neurological checks after a fall, and was not monitored for orthostatic hypotension while on Seroquel. Another resident did not receive neurological checks after an unwitnessed fall, despite documentation indicating they should have. These deficiencies were confirmed by staff interviews and record reviews.
A resident who lacked decision-making capacity was administered Ativan for anxiety without documented informed consent, as required by facility policy. Staff confirmed that when the medication was reordered after an initial period, the necessary informed consent process was not completed, and this was acknowledged by the DON.
The facility did not ensure consistent and accurate posting of Enhanced Barrier Precaution (EBP) signs for multiple residents colonized with MDROs, leading to staff confusion about required PPE. Staff interviews revealed uncertainty about the meaning of different colored isolation signs and the appropriate use of masks and gowns, while training records lacked evidence of specific instruction on these distinctions. These failures resulted in improper infection control practices for residents on EBP.
A resident with complex medical needs, including diabetes and gastroparesis, did not receive enteral feeding and medication through the correct ports of a GJ tube as ordered by the physician. Facility staff were unable to identify the G and J ports, did not notify the physician when unable to verify port placement, and had not received in-service training on GJ tube care. Additionally, there was no physician's order for the maintenance or discontinuation of the G tube drainage bag, resulting in the resident's transfer to an acute care hospital after the J tube became clogged and the resident experienced severe hypoglycemia.
A facility failed to ensure a POLST was signed and dated by a physician for a resident who lacked decision-making capacity. The POLST was incomplete, missing the healthcare provider's signature and date. Additionally, the facility did not provide an Advance Directive Acknowledgement form to the resident or their representative, as confirmed by staff interviews and medical record reviews.
The facility failed to complete PASRR screenings for two residents, leading to potential gaps in care. A resident readmitted after a hospital stay did not receive a new Level 1 PASRR screening, despite a recent depression diagnosis. Another resident, diagnosed with mild depression and prescribed mirtazapine, did not have a PASRR Level 1 Screening Resident Review Status Change performed. Staff confirmed these oversights, acknowledging the need for updated screenings to ensure appropriate care and resources.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks. One resident did not have a care plan for the use of elevated side rails, despite a physician's order. Another resident's care plan did not address their preference for a high bed, which increased the risk of falls. Staff confirmed the lack of appropriate care plans and interventions for these issues.
The facility failed to prevent pressure ulcers and ensure proper care for several residents. A resident developed a new blister that was not assessed or treated appropriately. Additionally, the facility did not consistently monitor and adjust the settings of low air loss (LAL) mattresses according to residents' weights, leading to incorrect settings for three residents. These deficiencies were confirmed by staff observations and interviews.
A facility failed to ensure a resident's GT feeding was properly connected, resulting in the feeding dripping onto the floor. The resident had a physician's order for continuous enteral feeding, but during an observation, it was found disconnected. Staff suggested the disconnection might have occurred after dialysis or during a shower. The issue was verified by RN and LVN, and the Administrator and DON were informed.
The facility failed to provide appropriate respiratory care for several residents, including incorrect oxygen administration, lack of required signage, and improper storage of respiratory equipment. These deficiencies were confirmed through observations and staff interviews.
A facility failed to provide appropriate dialysis care for a resident with ESRD by not completing required dialysis communication forms. The facility's P&P required pre- and post-dialysis checklists to be completed, but multiple entries were left blank. An LVN confirmed the oversight, acknowledging the forms should have been filled out.
The facility failed to ensure resident safety by not attempting alternatives or obtaining informed consent before using bed rails for two residents. One resident with impaired cognition used grab bars without documented consent or alternatives, while another with seizures had no assessment for entrapment risk or informed consent. Staff confirmed these omissions, posing potential entrapment risks.
A facility failed to administer medications via GT by gravity as per policy and did not check a resident's bowel pattern before giving a stool softener. An LVN used a syringe to push medication through the GT and relied on inaccurate verbal reports instead of reviewing the resident's documented history of loose stools.
A facility failed to monitor a resident's blood pressure and heart rate before administering amlodipine and losartan, as prescribed. The resident's physician orders required holding the medications if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 bpm. From November 1 to 19, there was no documented evidence of these checks, confirmed by an RN during a review.
The facility failed to ensure that two residents were free from unnecessary medications. A resident was prescribed zolpidem without a 14-day stop date, and another was given quetiapine fumarate without a documented diagnosis or clinical rationale. These issues were confirmed by facility staff during interviews.
The facility failed to ensure safe storage and management of medications, with expired medications found in a medication room and carts, unauthorized bedside storage of antifungal cream, and improper disposal of controlled substances. Additionally, medication carts contained expired supplies and improper storage of items, risking cross-contamination and unsafe administration.
Resident scratched during shower care by CNA with long nails
Penalty
Summary
The facility failed to ensure one of three sampled residents was provided care and services free from accidents and injuries when a CNA with long nails scratched the resident during shower care. Resident 1 had no capacity to understand and make his own decisions, and during showering the CNA was trying to manage the resident’s tracheostomy while rinsing his head and face. The CNA’s nails caused multiple linear superficial scratches to the resident’s forehead, cheeks, and chin, with no active bleeding and minimal redness noted. The resident’s licensed nurse progress note documented superficial scratch marks to the facial area, forehead, and both sides of the face after the shower incident. Interviews with nursing staff and the CNA confirmed that the scratches occurred while the CNA was providing care and that the CNA knew she should not have long nails. Facility records showed the dress code required nursing staff to keep nails trimmed to 1/8 inch to avoid injury to residents, and an inservice on nail hygiene and prevention of resident injury and infection had been provided to staff, including the CNA and an LVN who was observed with long, apparently artificial nails.
Unnecessary Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that three of five sampled residents reviewed for unnecessary medications were free from unnecessary psychotropic medication use. For Resident 14, who had no capacity to understand and make medical decisions, the record showed orders for Rexulti for dementia with agitation and venlafaxine for depression, with behaviors monitored each shift. During March 2026, the MAR documented 17 episodes of responding to internal stimuli leading to resisting care and one episode of sadness, but the record did not show any nonpharmacological interventions provided when those behavior episodes occurred. During the survey interview and record review, LVN 6 was unable to produce documentation of nonpharmacological interventions, and the DON was informed of the findings. For Resident 3, the record showed orders for buspirone for anxiety, lorazepam as needed for anxiety, and orthostatic blood pressure monitoring once a week related to the use of those medications. The MAR documented orthostatic blood pressures on two Sundays, but the sitting and lying readings were identical on both occasions, with no evidence in the record that the measurements were accurately obtained. During the interview and concurrent record review, RN 6 verified that the orthostatic hypotension monitoring was inaccurate because the same blood pressure readings were recorded for both positions, and the DON later verified the findings.
Improper LAL Mattress Settings for Two Residents
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for two residents who were receiving low air loss (LAL) mattress therapy for skin and wound management. Facility policy stated the manufacturer's guidelines should be reviewed for each individual mattress and followed if they differed from facility policy. The DynaRest Airfloat 100 Air Mattress with Pump manual stated the pressure adjust knob should be set using the weight scale as a guide. Resident 110 had no capacity to understand and make decisions, had a physician order for an LAL mattress with checks every shift, and weighed 128 pounds. During observation, the resident was lying on an LAL mattress with the pressure setting passed the 150 pounds mark, and the LVN verified both the setting and the resident's weight. Resident 8 also had no capacity to understand and make decisions, had a care plan for high risk for further skin breakdown and history of pressure ulcer, had a physician order for an LAL mattress with checks every shift, and weighed 120 pounds. During observation, the resident was lying on an LAL mattress with the pressure setting at the 150 pounds mark, and the LVN verified the setting and the resident's weight.
Respiratory Care and Oxygen Therapy Deficiencies
Penalty
Summary
The facility failed to provide necessary respiratory care services for multiple residents who were receiving ventilator or oxygen therapy. For Residents 3, 4, and 7, the ventilator machines were observed in use, but the record did not show physician orders or documented evidence for cleaning and disinfecting the ventilators according to the manufacturer’s recommendation. The ventilator operator’s manual stated the machine should be cleaned with medical detergent or alcohol-based cleaning solutions, rinsed with sterile distilled water, and wiped clean between patients and as needed while in use. RTs and RN staff acknowledged there was no documentation showing the ventilators had been cleaned, and RT staff were uncertain whether the manufacturer’s instructions were being followed. Resident 69, who had no capacity to understand and make decisions and had an order for oxygen at 4 LPM continuously to keep oxygen saturation above 92%, was found with the oxygen machine off and the oxygen tubing and nasal cannula touching the floor. During the observation, LVN 6 verified the tubing and cannula had been on the floor and stated the tubing should have been discarded and replaced before oxygen was administered. The LVN was observed preparing to connect the resident using the same nasal cannula that had been on the floor, and the resident’s oxygen saturation was 88% before oxygen was applied. After oxygen was started at 4 LPM, the saturation increased to 94%. Additional respiratory care issues were identified for other residents. Resident 94, who had capacity to understand and make decisions and had an order for oxygen via nasal cannula at 2 LPM as needed, was observed wearing oxygen without any No Smoking/Oxygen in Use sign posted inside or outside the room. Resident 136, who had no capacity to make decisions and had an order for oxygen at 2 LPM via nasal cannula, was observed with a motor-like sound coming from the oxygen concentrator, and the resident stated the sound bothered her. Resident 21, who was nonverbal and had no capacity to make decisions and had an order for albuterol via nebulizer as needed, was observed with nebulizer tubing touching the floor, and RN 5 verified the tubing was touching the floor.
Menu Not Followed for Pureed Korean Meals
Penalty
Summary
The facility failed to ensure the posted Korean lunch menu was followed for residents receiving pureed diets. During a puree food preparation observation, the cook stated he would puree the bulgogi and seaweed soup, while other menu items had already been pureed and refrigerated. When observed later, the cook poured seaweed soup into a blender and produced a liquified version of the soup, stating it was finished because Koreans liked to drink soup. The Dietary Services Director then instructed him to follow the IDDSI Level 4 soup recipe, which included saltine crackers, but the cook hesitated and the director later directed him to use thickener and omit the crackers after stating the RD had told her to do so by telephone. The observation also showed that the cook did not puree the roasted [NAME] listed on the menu, stating he would not be pureeing that item. He stated the kimchi was purchased in tubs and then pureed, but the Dietary Services Director said there was no specific puree recipe for kimchi. The RD later stated the puree recipes provided to the facility were challenging because they were not geared to Korean cultural foods, and she had not followed up because the recipes had been approved long ago by the company’s registered dieticians.
Food Safety and Hand Hygiene Lapses During Meal Preparation and Service
Penalty
Summary
Food safety and sanitation guidelines were not followed in the kitchen and during meal service. During observation, Tray Line Staff 1 was seen in the dishwashing area with strands of hair coming out of the side of the hairnet, and ten ladles were stored about two to three feet above the wash and rinse compartments of the three-compartment manual dishwash sink. The Dietary Services Director verified both findings. During dining observation, CNA 6 delivered Resident 105’s food tray to the resident without having a licensed nurse check the tray first, and CNA 6 verified the finding. In a puree food preparation observation, Cook 1 removed gloves, touched the barrel trash can to dispose of the used gloves, then put on new gloves and touched the blender without performing hand hygiene. Cook 1 also touched the trash can to dispose of used gloves, retrieved kimchi from the refrigerator, and retrieved a fork without hand hygiene in between, and did not acknowledge the findings when asked about the lack of handwashing.
Policy for Outside Food Did Not Address Storage or Reheating
Penalty
Summary
The facility failed to ensure its policy regarding personal food brought in from outside addressed residents who wanted to store and reheat those foods for later consumption. Review of the facility’s policy titled "Food and Liquids food From Outside Sources or Other Than the Dietary Department" revised 3/2025 showed that foods brought from outside could not be reheated or stored in the facility. The facility’s Order Listing Report dated 3/12/26 showed 48 of 124 residents, including 10 residents on puree diets, received meals prepared in the facility’s kitchen. During an interview on 3/11/26, the ADON stated there was no residents’ refrigerator. On 3/13/26, the RD stated she was aware of the policy not allowing residents to store or reheat foods brought from outside and stated she was not included in the development of the policy. On 3/18/26, the DON and Administrator were informed of the findings, and the DON stated personal food brought from outside was not to be stored or reheated per the facility’s policy.
Infection Control Program Not Implemented as Written
Penalty
Summary
The facility failed to implement its infection control program in accordance with its policies and procedures. The infection preventionist was responsible for surveillance and tracking of infections, and the facility stated it used McGeer's criteria to determine whether infections were true infections. Review of the monthly surveillance logs from September 2025 through February 2026 showed multiple infections categorized as healthcare-acquired infections, community-acquired infections, or did not meet McGeer's criteria. However, review of the surveillance data collection forms for several residents showed the forms were inaccurate or incomplete, including missing localizing symptoms, blank culture result sections, and mismatches between the form entries and the surveillance log classifications. For one resident treated for a UTI, the surveillance form documented fever but did not document the required localizing urinary symptoms, yet the infection was listed as a healthcare-acquired infection on the surveillance log. For other residents, the forms showed antibiotic treatment for leukocytosis, respiratory illness, or influenza-like illness, but the documented criteria on the forms did not support the selected infection classification. In several cases, cultures were obtained but the results were left blank on the surveillance forms, and in some instances the surveillance log listed a blood infection even though the form did not support that classification or the culture results were negative. One resident was listed on the surveillance log for a respiratory infection, but no surveillance form was completed to determine whether the infection met McGeer's criteria. The facility also failed to follow its Legionella water management procedures. Its building water system flowchart showed the flow of water through the facility and to three water heater tanks, but it did not identify the potential hazard areas where Legionella may grow. The water management program identified low water temperature as a hazard, and the maintenance director stated the facility monitored hot water temperatures and chlorine residuals; however, the main water pipe supplying the three water heater tanks was not being documented for temperature monitoring, and chlorine residual was only tested in the kitchen. During observation, one water heater tank showed a temperature below 120 degrees F while the other two were 145 and 155 degrees F. The facility also failed to follow infection control practices during resident care. A CNA picked up a resident's call light from the floor and placed it back on the resident's bed without disinfecting it first. Another CNA changed one resident's brief, removed gloves, and then entered another resident's room to turn off the call light without performing hand hygiene. In addition, an LVN was observed with long artificial fingernails extending about one-half inch beyond the fingertips while providing care.
Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident or the resident’s representative was fully informed in advance of the proposed treatment regarding the use of a psychotropic medication. For Resident 14, who was admitted to the facility and had an H&P showing no capacity to understand and make decisions, the medical record showed a physician’s order for venlafaxine 25 mg, 0.5 tablet via G-tube three times a day for depression as manifested by verbalization of sadness. The physician’s order indicated informed consent was obtained from the resident’s representative. Review of Resident 14’s informed consent form showed the representative was informed about venlafaxine, but the form did not include the list of possible nonpharmacological approaches that could address the resident’s behavior related to the medication. Facility policy required informed consent for psychotherapeutic medication to include reasonable alternative treatments, and the CDPH psychotherapeutic drug informed consent form also included reasonable alternative modes of treatment or possible non-pharmacological approaches. During interview and concurrent record review, RN 1 verified the informed consent for venlafaxine did not show the possible nonpharmacological approaches. The DON was informed of and acknowledged the findings.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123 for Resident 139 before discharge from Medicare Part A services. Resident 139 was admitted to the facility and had an H&P examination dated 7/7/25 showing the resident had no capacity to make medical decisions. Review of the facility's Beneficiary Notice - Residents discharged Within Last Six Months showed Resident 139 was to be discharged from the Medicare covered Part A stay on 9/25/25 and would be discharged home or to a facility for lesser care. However, the medical record did not show that Resident 139 and/or the resident's representative were provided a copy of the NOMNC form when the resident was to be discharged from Medicare Part A services. The BOM stated they were unable to locate the NOMNC form in the chart, and the DON was informed and acknowledged the findings.
Failure to Address Resident Grievance About Staff Conduct
Penalty
Summary
The facility failed to address a resident grievance in accordance with its grievance policy for one of 25 sampled residents, Resident 81. The facility’s grievance procedure stated that residents have the right to file grievances or complaints about resident treatment, medical care, and the behavior of other residents or staff members, and that the facility must make prompt efforts to resolve them. Resident 81 was admitted to the facility and had a history of being able to understand and make medical decisions, as documented in the resident’s H&P examination. During an interview, Resident 81 stated that LVN 10 had an attitude and told him he was pressing the call light too much during the evening shift. Resident 81 reported the interaction to RN 3. RN 3 stated she was made aware of the situation about two weeks earlier, that Resident 81 said LVN 10 was rude and gave him attitude when answering his call light, and that she did not document the interaction. RN 3 also stated she learned of the incident the following morning. The DON stated that complaints about staff being rude should be reported to Social Services so a grievance report could be initiated and an investigation conducted, but the resident’s concern was not addressed in that manner.
Failure to Document Least Restrictive Measures and Mitten Release
Penalty
Summary
The facility failed to ensure one sampled resident was free from the use of physical restraints unless needed for medical treatment. Resident 98, who had severely impaired cognitive skills for daily decision making, was observed lying in bed with a left hand mitten in place on 3/11/26 and again on 2/12/26. The resident was able to move the left arm and was observed touching the body while wearing the mitten. The physician's order dated 3/2/26 directed staff to apply a left soft hand mitten due to high risk for injury related to attempting to pull on medical devices, to monitor episodes of pulling on medical devices every shift, to release the mitten every two hours for at least 10 to 15 minutes for ROM, circulation, and skin integrity, and to check the mitten for proper fit and placement every shift. Review of the restraint assessment dated 10/27/25 showed the left hand mitten was used for the resident's risk of pulling on medical devices, but the assessment did not show that least restrictive interventions were attempted before the mitten was used. Review of the March 2026 MAR showed documentation for the two-hour mitten release, but there was no indication of when the mitten was released, what intervention staff provided during the release, or when it was reapplied. During interviews, CNA 5 stated the resident wore the mitten because he was pulling out his catheter. LVN 12 verified the order and stated staff were just watching the resident to make sure he would not grab his tubing, and also verified there was no documentation of when the mitten was applied or reapplied. RN 4 verified there were no least restrictive interventions attempted prior to application of the mitten, and the DON was informed and verified the findings.
Inaccurate MDS Coding for Resident With Right-Sided ROM Impairment
Penalty
Summary
Ensure each resident receives an accurate assessment was not met for one of 25 sampled residents, Resident 11, because the MDS was coded inaccurately for range of motion limitations. During observation and interview, Resident 11 was seen sitting in a wheelchair using an iPad with his left arm while not moving his right arm. He stated he had a stroke that affected the right side of his body and caused him to be unable to move his right arm and right leg. He also stated he had been this way for a long time and did not want exercises for range of motion. Medical record review showed Resident 11 was admitted with a history of stroke and had capacity to understand and make decisions. OT documentation showed impaired ROM in the right upper extremity, and PT documentation showed impaired right lower extremity with no impairment in the left lower extremity. The admission MDS coded impairment on one side of the upper and lower extremity, but a later MDS coded no impairment in both upper extremities and impairment in both lower extremities. The Director of Rehabilitation and the MDS Coordinator both stated Resident 11 had ROM impairment on the right upper and lower extremities, and the MDS Coordinator verified the 1/30/26 MDS was inaccurate and should have been coded as impairment on one side of the upper and lower extremity.
Failure to Coordinate PASARR Recommended Mental Health Services
Penalty
Summary
The facility failed to ensure coordination of PASARR and assessments for one sampled resident, who had a history of bipolar affective disorder. The resident’s H&P dated 9/14/24 documented the diagnosis, and the PASRR Notice of Individual Determination Letter dated 4/12/25 recommended specialized services including psychology consultation and psychotherapy/counseling services. During record review and interviews on 3/13/26, the MDS Coordinator stated the recommended psychology consultation and psychotherapy/counseling services were not completed. The MDS Coordinator also stated she did not follow up with PASRR staff to inform them that the resident had been diagnosed at the acute care hospital with bipolar disorder and to address the PASRR unit recommendations.
Inaccurate PASRR Screening and Missing Resident Review
Penalty
Summary
The facility failed to ensure that the level 1 PASRR contained accurate information for one resident with a diagnosis of psychosis. The resident’s level 1 PASRR dated 6/9/25 showed no diagnosis of mental illness and no prescribed psychotropic medications, and it was marked negative with no level 2 evaluation required because the resident was identified as not having a serious mental illness. However, the resident’s admission MDS assessment showed an active diagnosis of psychotic disorder, and the medical record also showed a physician order dated 10/8/25 for trazodone 50 mg at bedtime for depression-related inability to sleep. The record did not show that a level 1 PASRR Resident Review was completed during the initial stay for the inaccurate serious mental illness determination or when the new diagnosis of depression and trazodone order were added. The facility also failed to complete a Resident Review when the resident’s level 2 PASRR evaluation was inaccurate. The resident’s MDS assessment later showed functional limitations in range of motion in the bilateral lower extremities and increased dependence for multiple activities of daily living, including eating, oral hygiene, toileting, bathing, dressing, rolling, and bed mobility. Despite this, the level 2 PASRR letter dated 12/20/25 stated that after reviewing the positive level 1 screening and speaking with staff, a level 2 mental health evaluation was not scheduled because the individual had no serious mental illness and no functional limitation in the last six months, and the case was closed. The MDS Coordinator, MDS Nurse, and DON reviewed the record and acknowledged that the level 1 screening and level 2 evaluation were inaccurate and that a Resident Review should have been conducted.
Failure to Include Individualized Care Plan Problems for a CGM Device and IV Site
Penalty
Summary
The facility failed to develop comprehensive care plans that reflected the individual care needs of two residents. Facility policy required a resident-centered comprehensive care plan for each resident, including measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs, and to be completed within seven days of assessment completion. For one resident, the physician ordered use of a Dexcom G7 continuous glucose monitoring receiver for diabetes, but the comprehensive care plan did not include a problem addressing the blood glucose monitoring device. An RN verified that no care plan had been formulated for the device, and the DON later confirmed this finding. For another resident, who was readmitted with muscle weakness and hemiplegia and was nonverbal with no decision-making capacity, the physician ordered IV vancomycin through a peripheral IV in the right arm, but the comprehensive care plan did not include a problem addressing the IV site. An RN verified that a care plan for the IV site had not been developed.
Care plans not updated to reflect current resident needs
Penalty
Summary
The facility failed to keep the comprehensive care plan current for five sampled residents by not revising interventions to match their current care needs. The report states that the care plan was not revised within the required timeframe and was not consistently updated to reflect changes in the residents and services provided. Surveyors reviewed the facility policy on comprehensive care planning and found that the care plan must be reviewed and revised periodically and on an ongoing basis to reflect changes in the resident. For three residents who had tracheostomies connected to ventilator machines, the care plans addressed impaired gas exchange and ventilator management, but did not include cleaning and disinfecting the ventilator machines per the manufacturer's manual. The records for these residents did not show a physician order for cleaning and disinfecting the ventilator machines per manufacturer recommendations, and there was no documented evidence that the cleaning and disinfecting had been recorded. RN 6 verified that the care plan interventions did not include the cleaning and disinfecting of the ventilator machine per the manufacturer's manual, and the DON acknowledged the findings. For another resident, the care plan for weight loss still included monitoring meal intake even though the resident was NPO except for medications and Boost supplements, and the hydration care plan did not reflect the resident's current IV hydration therapy. For the fifth resident, the care plan for left hand mittens included checking and releasing the mittens every two hours for skin integrity and circulation, but did not include the use of least restrictive interventions when the mitten was released. RN 2 and RN 4 verified the findings during record review, and the DON was informed and acknowledged the issues.
Failure to Follow Orders for Glucose Monitoring, Insulin Site Rotation, and Medication Hold Parameters
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided for a resident using a Dexcom G7 continuous glucose monitor. The resident, who had diabetes mellitus and was cognitively intact, was observed with the Dexcom G7 box and equipment at bedside but without the probe attached to the skin. The resident stated the facility did not have a new one, and staff confirmed the resident had no device applicator in place. Review of the physician order summary showed an order for the Dexcom G7 receiver device, but there was no physician order for care of the monitor probe on the resident’s skin, no order for skin assessment of the application site, no monitoring instructions for whether the device was functioning correctly, and no care plan for the device. The facility also failed to rotate insulin injection sites for another resident who received scheduled NPH insulin and sliding-scale lispro insulin for diabetes mellitus. Review of the medication administration records for multiple months showed repeated insulin administration in the left upper quadrant of the abdomen on numerous dates and times, rather than rotating sites. During interview, an RN acknowledged that insulin injection sites should be rotated to prevent complications related to medication injection, and the DON later verified the findings. For a third resident with no capacity to understand and make decisions, the facility failed to follow physician-ordered hold parameters for cardiac medications. The resident had orders for digoxin to be held if pulse was below 60 beats per minute and metoprolol to be held if systolic blood pressure was less than 110 mmHg or pulse was less than 60 beats per minute. The MAR showed metoprolol was administered when blood pressure was 104/46 mmHg and pulse was 56 beats per minute, and digoxin was administered when pulse was 58 beats per minute. An LVN verified the documentation and could not confirm the medications had been held as ordered, and the DON acknowledged the findings.
Restorative Nursing Services Not Provided as Ordered and Resident Not Informed of Reduced Service Impact
Penalty
Summary
The facility failed to ensure appropriate restorative nursing services were provided for a resident with impaired ROM after a stroke affected the right side of his body. The resident was admitted with impaired ROM on one side of the upper and lower extremity and had physician orders and a restorative nursing referral that differed from the therapy discharge recommendation. The physician order dated 12/31/25 directed RNA services for bilateral lower extremity AAROM and bilateral upper extremity AROM three times weekly, while the restorative nursing referral/care plan dated 12/19/25 directed bilateral lower extremity AAROM and bilateral upper extremity AROM five times weekly. The OT discharge summary also recommended RNA provide bilateral upper extremity AROM five times weekly. During interview, the RNA stated he had been providing PROM to the resident's right upper extremity since beginning services and documented it, but did not realize the order showed AROM. He also stated he did not follow up with therapy regarding the recommendation when he was providing PROM instead of the ordered AROM. The Director of Rehabilitation stated the resident had impaired ROM on the right upper extremity upon admission and required PROM to maintain current ROM, and that the RNA treatment recommendation should have been PROM rather than AROM. The Director of Rehabilitation further stated the RNA should have communicated with rehabilitation when providing PROM despite the OT recommendation and physician order indicating AROM. The facility also reduced the resident's RNA services from five days per week to three days per week at the resident's request, but the record did not show that the resident was informed of the risk of possible ADL decline associated with the reduced frequency. RN staff confirmed the reduction and stated the resident could experience a decline in ADL functioning if he did not receive RNA services as recommended. The resident had the capacity to understand and make decisions, but documentation was not found showing that he was educated about the potential impact of reducing the restorative services.
GT Feeding Care and Labeling Deficiencies
Penalty
Summary
The facility failed to provide necessary GT care and services for two residents receiving tube feedings. Resident 98 was GT feeding dependent and had physician orders for Glucerna 1.5 at 65 mL per hour via enteral pump, with residual checks every shift and instructions to hold the feeding if residuals were above 100 mL. During multiple observations, Resident 98 was found lying in bed asleep with the feeding infusing while the head of the bed was only slightly elevated and not at least 30 degrees. During a bedside interview, an LVN verified the feeding was infusing and the bed was not elevated to at least 30 degrees, and stated the elevation should be 30 degrees or more to prevent aspiration. Resident 5 had physician orders for Nepro 1.8 via enteral pump at 60 mL per hour and for the GT to be flushed with a minimum of 5 mL of water every hour for 16 hours. During observation, Resident 5 was lying in bed with the feeding tube and water bag connected to the feeding pump, which was off, and the water bag was not labeled with the date and time it was connected. An LVN verified the water bag was not labeled and stated staff should have labeled the tubing when the water flush via feeding pump was started. The DON was informed and acknowledged the findings for both residents.
IV Dressing Not Dated and IV Tubing Not Discarded on Time
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for IV therapy for two residents. Resident 21 was receiving IV vancomycin for right chest wall cellulitis and was nonverbal with no capacity to make decisions. During observation, the resident was found in bed with an empty vancomycin container hanging from the IV pump, and the IV site on the right arm was covered with tape. When the RN uncovered the site, there was no label or date on the IV dressing, and the RN verified the dressing was not dated. A later interview with another RN confirmed the IV site dressing should have been labeled with the date. Resident 73 was observed with a one-liter bag of D5 0.9% NS with 20 mEq KCL infusing into the left arm. The IV tubing label showed it was for 72 hours only, with a start date of 3/6/26 and a discard date of 3/9/26, but the tubing was still in use on 3/11/26. The resident had a physician's order for continuous IV hydration, and the IV MAR included directions to change the tubing every 72 hours if used for IV fluids only. RN 1 stated the tubing should have been discarded on 3/9/26, and the DON acknowledged that the RN should check the tubing label and discard it if past the discard date.
PRN Pain Medication Given Outside Ordered Pain Parameters Without Documented Nonpharmacological Interventions
Penalty
Summary
The facility failed to provide safe, appropriate pain management for Resident 31 by not administering PRN hydrocodone-acetaminophen in accordance with the physician’s orders and by not documenting nonpharmacological pain interventions before giving the medication. Resident 31 was admitted to the facility and had no capacity to understand and make decisions. The physician ordered hydrocodone-acetaminophen 5-325 mg, one tablet every four hours as needed for moderate pain rated 4 to 6, and two tablets every four hours as needed for severe pain rated 7 to 10. Review of the MAR showed multiple administrations of the one-tablet dose when the documented pain level was outside the ordered range, including when pain was rated 7 and when pain was rated 3, and multiple administrations of the two-tablet dose when pain was rated 6. The MAR also showed repeated PRN doses in February and March 2026, but the medical record did not contain documented evidence of nonpharmacological pain interventions attempted before those administrations. The LVN and DON both acknowledged that the record lacked documentation of the required nonpharmacological interventions and their effectiveness.
Controlled medication administration not documented on MAR
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services by not ensuring that administration of a controlled medication was documented on the MAR for one nonsampled resident. Facility policy for controlled medications required the licensed nurse to immediately enter the date and time of administration, amount administered, and the nurse’s initials on the MAR after the medication was given, as well as sign the accountability record when the dose was removed from supply. Resident 99 was admitted and later readmitted to the facility, and the H&P dated 1/21/26 stated the resident had no capacity to understand and make decisions. The resident had an order dated 1/21/26 for hydrocodone-acetaminophen 10-325 mg, one tablet by mouth every four hours as needed for severe pain, not to exceed 3 gm per 24 hours. The controlled drug record showed one Norco tablet was dispensed and signed out on 3/13/26 at 0630 hours, and LVN 4 verified the tablet was pulled at 0635 hours; however, the MAR for March 2026 did not show documentation that the medication was administered. The DON also verified there was no documented evidence on the MAR that the Norco was administered and stated the process was to assess the resident, check the order, pull the medication, sign the Individual Narcotic Record, administer the medication, then document it on the MAR.
Improper Medication Storage, Labeling, and Disposal
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with facility policy and accepted medication storage practices. During a medication cart inspection of Medication Cart F with LVN 3, surveyors observed one bottle of aspirin stored in the same cube as five boxes of artificial tears, and one bottle of ibuprofen, vitamin C, acetaminophen tablets, and docusate sodium stored in the same cube as 18 rivastigmine transdermal patches and a box of cyclosporine ophthalmic emulsion. Surveyors also observed opened boxes of ipratropium-albuterol inhalation solution for two residents that were not labeled with the opened date. LVN 3 confirmed the findings and stated internal and external medications should not be stored together because they are administered by different routes and could cause medication errors and contamination, and that opened medications should be labeled with the date opened. Surveyors also observed improper disposal of Resident 21’s vancomycin IV supplies. An IV tubing, normal saline bag, and empty vancomycin container were found discarded in the resident’s personal trash can. RN 3 verified the disposal, and RN 7 stated she had placed the items there and did not know the facility’s policy for disposing of medications after use. The ADON was informed and confirmed that medication supplies and containers should not be thrown into residents’ trash cans.
Pureed Meal Preparation and Kimchi Temperature Issues
Penalty
Summary
The facility failed to ensure American and Korean pureed food preparations were not conducted too far in advance of serving time. The Dietary Services Director stated lunch was served starting at 1130 hours, while the Korean puree preparation started at 0930 hours and the American puree preparation started at 1000 hours. During observation, one dietary staff member stated he was pureeing Bulgogi and seaweed soup and that other menu items had already been pureed earlier in the morning and were refrigerated. Another dietary staff member was observed starting the American menu puree and stated he was pureeing food for two residents, with other food items having been pureed earlier in the morning. The facility also failed to ensure staff were knowledgeable about the serving temperature for kimchi. During tray line observation, a dietary aide stated the kimchi was 56 degrees Fahrenheit and said it should be served at less than 40 degrees Fahrenheit, then placed it in ice to lower the temperature. A second temperature reading showed the kimchi at 48 degrees Fahrenheit. At that time, the Dietary Services Director stated Koreans liked eating kimchi at room temperature so 48 degrees Fahrenheit was okay to serve. The RD later stated she was aware kitchen staff were doing the puree preparations too far in advance of serving times.
Failure to Provide Ordered Sippy Cup for Resident 33
Penalty
Summary
The facility failed to ensure that Resident 33 was provided the adaptive eating equipment ordered for her meals. During a lunch observation, Resident 33 was seated in the dining room and assisted with lunch by RNA 1. She was served a four-ounce carton of mighty shake, a cup of milk, and a cup of pink-colored beverage, and RNA 1 placed straws in the mighty shake and the pink-colored beverage for her to drink. However, the resident’s lunch meal ticket listed a sippy cup and one-to-one feeding assistance, and a sippy cup was not observed being used for her beverages. Review of the medical record showed a physician’s order dated 2/26/26 stating that Resident 33 may have a sippy cup with meals per the family’s request. During concurrent interview and observation, LVN 1 verified that the resident should have been served her beverages in the sippy cup and then provided the sippy cup to RNA 1. The DON later reviewed the record and confirmed the findings, stating that if there was a physician’s order and the meal ticket indicated a sippy cup, the resident should have been served her beverages in the sippy cup.
Missing Pharmacist Documentation for P&P Review
Penalty
Summary
The facility failed to ensure documented evidence of compliance with State law related to pharmaceutical services policy and procedure review. During review of the facility's Policy and Procedure Review dated 10/9/25, the document did not show that the facility's pharmacist had attended the review, as required by Title 22, Chapter 3, Section 72525. The report states that each facility must have a pharmaceutical service committee and that minutes of committee meetings must include the names of members present, but the reviewed document did not include the pharmacist's participation. On 3/17/26 at 1553 hours, a sign-in sheet for the review of the facility's policies and procedures was requested from the DON. During an interview on 3/17/26 at 1029 hours with the DON and Administrator, the DON stated the pharmacist attended quarterly and that the pharmacist's signature should have been on the P&P review dated 10/9/25. The DON and Administrator were informed that the pharmacist's signature was not on the document, and on 3/20/26 no sign-in sheet had been received to show documented evidence that the pharmacist participated in reviewing the facility's P&P.
Inaccurate resident records for nutrition assessment, POLST, MAR, and IV site documentation
Penalty
Summary
The facility failed to keep medical records accurate for four sampled residents. For Resident 73, the Nutrition Risk Assessment was completed incorrectly because the licensed nurse selected a score for an albumin level of 3.5 to 5.0 g/dL even though the resident’s hospital record showed an albumin level of 2.5 g/dL. The DON stated the assessment was completed on admission and should have been based on the resident’s medical records, and that the nutrition risk score determined nutritional management and interventions. For Resident 11, the POLST was not accurate because it showed no advance directive even though the resident had an Advance Health Care Directive Form completed later. The resident’s H&P showed the resident had capacity to understand and make decisions, and the medical record did not show that the POLST was updated to reflect the advance directive status. An LVN confirmed the discrepancy and stated staff refer to the POLST to determine whether to provide life-sustaining treatment during an emergency. For Resident 8, the MAR for March 2026 documented furosemide as administered even though the resident’s blood pressure was 104/46 mmHg and the physician’s order required the medication to be held if systolic blood pressure was less than 110 mmHg. The LVN verified that she had held the medication but mistakenly documented it as given. For Resident 21, the RN did not document the condition of the IV site even though the IV was no longer patent, swelling was observed near the site, and the resident indicated pain when the site was flushed. The RN verified that the IV site condition had not been documented.
Incomplete Hospice Coordination and Documentation
Penalty
Summary
The facility failed to ensure coordination of hospice services for one of two final sampled residents reviewed for hospice, Resident 31. Resident 31 was admitted to the facility and had an H&P examination dated 8/4/25 showing no capacity to understand and make decisions. A physician order dated 11/5/25 admitted Resident 31 to Hospice A for routine level of care, but the Order Summary Report did not show the frequency of hospice staff visits. Review of Resident 31's hospice documentation showed the March 2026 hospice calendar listed only a hospice RN visit on 3/24/26 and did not list other hospice staff names for the week of 3/22/26. The Hospice A Plan of Care dated 1/27/26 included hospice aide interventions for linen changes, sponge baths, and dressing three times per week, but the Hospice A Visit Description Log showed the hospice aide visited twice weekly on multiple dates in February and March 2026. The log also showed hospice RN visits on 2/9, 2/23, and 3/3/26, a hospice aide visit pattern on several dates, a hospice social worker visit on 2/27/26, and a hospice licensed nurse visit on 3/5/26. Resident 31's hospice record did not contain nursing progress notes for the listed hospice RN, aide, social worker, and licensed nurse visits, and it also lacked documentation of the hospice aide and social worker visitation notes for those visits. During interviews with the DON, the DON stated the hospice binder was intended to coordinate care between the facility and hospice agency, that the hospice calendar should show scheduled hospice visits and be updated monthly, and that hospice staff were responsible for placing progress notes in the binder after each visit. The DON also stated the RN Supervisors were responsible for checking the hospice binders after each visit, and later acknowledged that the hospice plan of care incorrectly listed the hospice aide visit frequency and should have been reviewed for accuracy.
Failure to Apply McGeer's Criteria for Antibiotic Use
Penalty
Summary
The facility failed to accurately determine whether one sampled resident and seven nonsampled residents met the criteria for a true infection before antimicrobial therapy was prescribed. Residents 16, 34, 45, 76, 78, 99, 117, and 143 were identified as receiving antimicrobial therapy even though they did not meet McGeer's criteria for infection, and the facility did not consistently classify these cases as DNMC. The facility's Infection Control Program System policy stated that the infection control program included preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, and that the IP would collect and analyze surveillance data using the facility's surveillance tools and revised McGeer's Criteria. The facility's Antibiotic Stewardship policy stated that the IP, DON, and pharmacy consultant would maintain a separate report for residents on antibiotics who did not meet McGeer's criteria for active infection and would collect information on the antibiotic ordered, route, culture results, and changes during treatment. Review of the monthly Infection Prevention and Control Surveillance Logs from September 2025 through February 2026 showed multiple DNMC cases each month. During interview and record review, the IP stated she completed a Surveillance Data Collection Form for residents with signs and symptoms of infection and for residents admitted on antimicrobial therapy, and that she used McGeer's criteria to determine whether an infection was HAI, CAI, or DNMC. However, the IP verified that Residents 16, 45, and 117 had infections that did not meet McGeer's criteria but were still prescribed antibiotics and were not marked as DNMC. For Residents 34, 76, 78, 99, and 143, the IP verified antimicrobial therapy was given even though blood infection cases did not have positive blood culture results, and she stated she used constitutional criteria such as fever, leukocytosis, acute mental status change, or acute functional decline to determine a true infection. The IP was unable to provide the reference literature for that determination and later stated she did not use the proper criteria for blood infections. Resident 99 also had two infections in February 2026, but the Surveillance Data Collection Form was not completed to determine whether the respiratory infection met McGeer's criteria.
Nurse Staffing Information Not Posted in Visible Location
Penalty
Summary
The facility failed to ensure the nurse staffing information was posted daily in a prominent place accessible to residents and visitors. Review of the facility policy titled Staffing Nurse Information showed that staffing information was to be posted daily and placed in a prominent location readily accessible to residents and visitors. During a concurrent observation and interview with the DSD, the Daily Nurse Staffing Information was observed posted sideways between a vase and other paperwork at station 2 on the SNF side, making it not visible to residents and visitors. The staffing data was also dated 3/16/26 rather than the current date of 3/17/26. The DSD stated the RN supervisor was supposed to post the current staffing data but forgot, and verified that the posted information was not current and was not in a visible place accessible to residents and visitors.
Failure to Follow Care Plan for Hand Mitten Restraint Use
Penalty
Summary
Surveyors identified that the facility did not follow the care plan and policy for restraint use for one resident who had a physician’s order for a left hand mitten due to persistent pulling out of a gastrostomy tube (GT). The facility’s Physical Restraints policy, revised 1/2017, required that when restraints are used, the resident must be provided with motion and exercise for at least 10 minutes during each two-hour period. The resident’s care plan for use of the left hand mitten, initiated on 3/10/25 and revised on 11/9/25, included an intervention to apply the left hand mitten to prevent pulling out the tube and to release it every two hours for 15 minutes for circulation and comfort. Review of the resident’s medical record, including the MAR for March 2025, showed that the left hand mitten placement was monitored every shift from 3/10 to 3/31/25, but there was no documented evidence that the mitten was released every two hours as required by the care plan. During an interview and concurrent record review, an RN stated that the facility protocol for hand mitten restraints was to remove them every two hours and check circulation and skin condition, but confirmed that there was no physician order to monitor circulation and skin condition every two hours and no documentation that the mitten was released every two hours for circulation and comfort. The Administrator was informed of and acknowledged these findings.
Failure to Provide and Document Ordered Ophthalmic Medications
Penalty
Summary
The facility failed to provide ordered ophthalmic medications for a resident and did not ensure timely administration or appropriate documentation when doses were missed. The resident, who had glaucoma and no capacity to understand or make decisions, had physician orders for Refresh Plus eye lubricant every two hours for dry eyes and ocular surface irritation, Timoptic (timolol) twice daily for uncontrolled primary open angle glaucoma, and Lumify (brimonidine tartrate) twice daily for ocular hyperemia. Review of the MAR showed multiple missed doses of these medications. On one date, Refresh Plus was coded as held and as not given due to vitals being outside parameters, but the progress notes did not document the reason or specify what parameters were not met. On subsequent dates, Refresh Plus was not administered numerous times over two days, with MAR notes indicating the facility was awaiting medication from the pharmacy. Further review showed that Timoptic was not administered at scheduled times on two separate dates, with one entry lacking any documented reason and another indicating the facility was awaiting delivery. Lumify was also not administered at a scheduled time, and nursing notes documented multiple follow-up calls to the pharmacy, which reported it did not have Lumify in stock. There was no documentation that the physician was notified of the multiple missed doses of these ordered medications. During interviews, RN 1 confirmed that charge nurses were responsible for requesting refills five days before medications ran out and acknowledged that the physician should have been informed when medications were not administered as ordered. The DON and Administrator were informed of and acknowledged these findings.
Failure to Develop Individualized Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop an individualized care plan to address a resident's actual fall incident that occurred on 11/22/24. Review of the resident's medical record showed that the resident was found on the floor on the right side of the bed in a side-lying position. The resident's history and physical examination indicated that the resident lacked the capacity to understand and make decisions. Despite this incident, the resident's plan of care did not include a problem or intervention related to the fall. Interviews with facility staff, including an RN and the DON, confirmed that there was no care plan developed to address the resident's fall. The facility's policy on comprehensive care planning requires that the plan of care include measurable objectives and timeframes and describe the services to be provided to maintain the resident's highest practicable level of well-being. The DON acknowledged that it was the responsibility of the licensed nurse to update the care plan with each change of condition, which was not done in this case.
Failure to Follow Physician Orders and Complete Required Monitoring After Falls
Penalty
Summary
The facility failed to provide necessary care and services for two residents by not following physician recommendations and not completing required monitoring after incidents. For one resident, a psychiatric evaluation recommended starting Depakote for poor impulse control, but there was no documentation that this recommendation was communicated to or obtained from the physician, and the medication was not initiated. Additionally, after this resident experienced a fall, the medical record did not show evidence that neurological checks were performed as documented in the progress note, despite facility policy and staff statements indicating that such checks should be completed for 72 hours post-fall. The same resident was later prescribed Seroquel for mood disturbance, with informed consent obtained from the responsible party. However, there was no documented evidence that orthostatic hypotension monitoring was implemented, even though this is a known side effect of Seroquel and was acknowledged as necessary by the DON. The lack of monitoring for orthostatic hypotension was verified during interviews and record reviews with facility staff. For a second resident, after an unwitnessed fall, the progress note and IDT recommendation indicated that neurological checks should be performed for 72 hours. However, the medical record did not contain documentation that these checks were initiated. Both RN 1 and the DON confirmed that neurological checks were not completed as required, despite the resident's lack of capacity to make decisions and the facility's policy to monitor for changes in neurological status after a fall.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, Ativan, for one resident. According to the facility's policy and procedure on psychotherapeutic drug treatment, informed consent must be obtained from the resident or their representative prior to the use of such medications, including providing information about the need for the medication, its desired effects, and potential side effects. The resident in question was determined to lack capacity to make decisions, and a physician's order was given to administer Ativan for anxiety. However, a review of the resident's medical record did not show any documented evidence that informed consent was obtained for the use of Ativan as ordered. Interviews with facility staff, including an RN and the DON, confirmed that a new informed consent was not obtained when the Ativan medication was ordered. The Ativan prescription was not renewed after an initial 14-day period, and when it was reordered, the required informed consent process was not completed. This failure was acknowledged and verified by the DON during the survey.
Failure to Implement Consistent Enhanced Barrier Precautions and Staff Training
Penalty
Summary
The facility failed to implement effective infection control practices for seven non-sampled residents who were under Enhanced Barrier Precautions (EBP) due to colonization with multidrug-resistant organisms (MDROs) such as CRE, C. auris, and CRAB. Observations revealed that EBP signs posted outside resident rooms were inconsistent and, in some cases, incorrect. For example, one room displayed a red sign requiring staff to wear an N-95 mask for a resident with CRE, which was not necessary according to facility policy. Other rooms had both standard EBP signs and additional colored signs (red or pink), each listing different PPE requirements, leading to confusion among staff. Interviews with staff, including LVNs, CNAs, RNs, and the Infection Preventionist (IP), demonstrated a lack of understanding regarding the meaning and requirements of the different colored isolation signs. Some staff incorrectly believed that an N-95 mask was required for EBP precautions, while others could not distinguish between the red and pink signs or their associated PPE protocols. The IP confirmed that the red and pink signs were intended to indicate additional infections and PPE needs but acknowledged that the signage was not always accurate and that staff training on the distinction between the signs was insufficient. Further review of training records showed that while staff had received general in-service training on EBP precautions, there was no documentation of specific training on the differences between the red and pink isolation signs. The lack of clear, consistent signage and inadequate staff training on EBP protocols resulted in improper implementation of infection control measures for residents colonized with MDROs.
Failure to Provide Appropriate GJ Tube Care and Adhere to Physician Orders
Penalty
Summary
The facility failed to provide necessary enteral care and services to a resident with a GJ tube, resulting in the resident receiving enteral feeding through the incorrect port. Staff were unable to accurately identify the G and J ports of the GJ tube, and as a result, enteral feeding was administered through the G tube port instead of the J tube port as ordered by the physician. Additionally, medications were administered through the incorrect port, and staff did not notify the physician when they were unable to verify the correct ports. The staff also did not receive in-service training on the care and management of a resident with a GJ tube prior to being assigned to the resident. The resident in question had significant medical needs, including diabetes, gastroparesis, ventilator-dependent respiratory failure, and was dependent on staff for activities of daily living. The resident was admitted with a GJ tube, with physician orders specifying that enteral feeding should be administered through the J tube port and medications through the G tube port. Despite these orders, staff were unable to confirm the correct port for feeding and medication administration, and did not seek clarification from the physician or other clinical leaders. The ports on the GJ tube were not labeled, contributing to the confusion among staff. Furthermore, the facility failed to obtain a physician's order for the maintenance and discontinuation of the G tube drainage bag. The resident was admitted with a drainage bag attached to the G tube port, but there was no documentation of a physician's order for its use or discontinuation. These failures led to the resident's transfer to an acute care hospital for medical intervention after the J tube became clogged, and the resident experienced a critical drop in blood sugar level.
Incomplete POLST and Missing Advance Directive Acknowledgement
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life-Sustaining Treatment (POLST) form was signed and dated by a physician, nurse practitioner (NP), or physician assistant (PA) for a resident who lacked the capacity to understand and make decisions. The POLST, dated 7/24/24, was incomplete in the Information and Signatures section, lacking the necessary documentation of the healthcare provider's name and date signed. This oversight was confirmed during an interview and medical record review with RN 1, who acknowledged the absence of the required signature and date on the POLST. Additionally, the facility did not provide an Advance Directive Acknowledgement form to the resident or their representative, which is used to offer information about advance directives. This was verified by both RN 1 and the Social Services Director (SSD), who confirmed the absence of the form in the resident's medical record. The Administrator and Director of Nursing (DON) also verified these findings during an interview, acknowledging the lack of documentation for both the POLST and the Advance Directive Acknowledgement form.
Failure to Complete PASRR Screenings for Residents
Penalty
Summary
The facility failed to ensure the completion of PASRR screenings for two residents, leading to potential gaps in care for mental illness or intellectual disabilities. Resident 76 was readmitted to the facility after a hospital stay exceeding 72 hours, which should have triggered a new Level 1 PASRR screening according to the facility's policy. However, the medical record showed no evidence of a PASRR being completed upon readmission, despite the resident's recent diagnosis of depression. Interviews with the LVN and ADON confirmed the oversight, acknowledging that the PASRR should have been updated to ensure appropriate care and resources were provided. Similarly, Resident 61 was diagnosed with mild depression and prescribed mirtazapine after the initial PASRR Level 1 screening indicated no serious mental illness or psychotropic medication use. Despite this change in mental health status, a PASRR Level 1 Screening Resident Review Status Change was not performed. The DON confirmed that the screening should have been updated to reflect the resident's new diagnosis and medication, which would have ensured the facility provided the necessary care for the resident's mental health needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, which posed a risk for not providing appropriate and individualized care. For Resident 73, the facility did not create a care plan to address the use of elevated side rails, despite a physician's order for bilateral grab bars for bed mobility and repositioning. During an interview, RN 1 confirmed that a care plan specific to the use of side rails was not developed for Resident 73, even though the resident utilized the grab bars to get up in bed. For Resident 88, the care plan did not address the resident's preference for a high bed, which was contrary to the intervention of maintaining the bed in the lowest or locked position to prevent falls. Despite the resident's noncompliance and preference for a high bed, no interventions or alternatives were offered to mitigate the risk of falls. RN 3, LVN 7, and CNA 3 acknowledged the resident's preference and the absence of floor mats, confirming that no care plan was developed to address the resident's noncompliance and risk of falls.
Failure to Monitor and Adjust LAL Mattress Settings and Address Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent pressure ulcers for several residents, including Resident 334, who developed a new blister on the right great toe. The facility did not assess the skin, inform the physician of the new skin condition, or provide appropriate treatment. A family member had notified a nurse about the blister, but the dressing was incorrectly placed on the opposite side of the toe. LVN 3 later acknowledged the presence of the blister and confirmed it was a Stage 2 pressure injury, but no prior assessment or treatment had been conducted. For Resident 3, the facility did not consistently monitor the settings of the low air loss (LAL) mattress, which was set incorrectly for the resident's weight. Despite a physician's order to use the LAL mattress for skin maintenance and monitor its placement every shift, the mattress was set to less than 80 pounds, while the resident's weight was 119 pounds. LVN 9 confirmed the incorrect setting and acknowledged that the mattress should have been set between 100 - 120 pounds. Similarly, Resident 102 and Resident 103 also experienced issues with the LAL mattress settings. Resident 102's mattress was set to more than 150 pounds, while the resident weighed 100 pounds. LVN 4 verified the incorrect setting. For Resident 103, the mattress was set between 120 to 155 pounds, although the resident weighed 88 pounds. LVN 3 confirmed the discrepancy and stated that the mattress pressure setting should be based on the resident's weight to prevent skin breakdown or worsening of wounds.
Failure to Ensure Proper GT Feeding Connection
Penalty
Summary
The facility failed to provide the necessary gastrostomy tube (GT) care and services for a resident who was reviewed for tube feeding. The resident, who was readmitted to the facility, had a physician's order to receive Nepro 1.8 enteral feeding via an enteral pump at a rate of 50 ml per hour over 16 hours. However, during an observation, it was found that the GT feeding was not connected to the resident, and the feeding was dripping onto the floor instead. This oversight was verified by RN 4, who acknowledged the issue and stated the need to inform the charge nurse. Further investigation revealed that the disconnection might have occurred after the resident's dialysis session or during a shower given by the facility staff, as mentioned by LVN 10. The LVN confirmed that the GT feeding was not connected and indicated that the entire feeding setup needed to be changed. The facility's Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Inadequate Respiratory Care and Safety Measures
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as evidenced by multiple observations and interviews. Resident 75 was observed receiving oxygen at three liters per minute, contrary to the physician's order of two liters per minute. Additionally, there was no 'No Smoking/Oxygen in Use' sign outside the resident's room, and the suction machine at the bedside lacked a physician's order and care plan. The suction storage bag was also undated and unlabeled, which was confirmed by LVN 15 and LVN 4 during their interviews. Resident 8 was observed with oxygen at three liters per minute, but there was no 'No Smoking/Oxygen in Use' sign posted as required by the facility's policy. Furthermore, the nasal cannula attached to Resident 8's wheelchair was not stored in a sanitary manner, as it was hanging on the wheelchair without a clean bag. This was verified by RN 5 and LVN 6, who acknowledged the need for proper signage and infection control measures. Resident 58's CPAP mask was found on the floor, and there was no respiratory bag at the bedside for proper storage. The facility also failed to have a physician's order for the CPAP settings, which was confirmed by the DON. Resident 44 was observed receiving oxygen at a rate higher than prescribed, and Resident 29 did not have the required 'No Smoking/Oxygen in Use' sign posted. These deficiencies were acknowledged by the facility's staff, including the Administrator and DON, during interviews.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 82, who required such services. The deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P) regarding dialysis care. The facility's P&P, revised in January 2019, mandates that a pre-dialysis checklist be completed each time a resident is scheduled for dialysis, which includes assessing the type and condition of the access site and dressing. Additionally, a post-dialysis checklist is required to document similar information. However, the review of Resident 82's dialysis communication assessment forms revealed multiple instances of incomplete documentation, with blank entries on specific dates for both pre-dialysis and post-dialysis assessments. Resident 82, who was admitted to the facility with a diagnosis of end-stage renal disease (ESRD) and was dependent on renal dialysis, had no capacity to understand and make decisions, as noted in their health and physical examination. The resident's medical records showed a physician's order for hemodialysis three times a week. Despite this, the facility failed to complete the necessary dialysis communication forms on several occasions, as verified by LVN 12 during an interview. LVN 12 acknowledged that the forms should not have been left blank and should have been filled out as required, indicating a lapse in the facility's adherence to its own dialysis care policies.
Failure to Ensure Resident Safety with Bed Rail Use
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 46 and 73, remained free from accident hazards related to the use of bed rails. For Resident 73, the facility did not attempt alternatives or obtain informed consent before using side rails. The resident, who had moderately impaired cognition, was observed using the grab bars for bed mobility, but there was no documentation of informed consent or attempts at alternative measures in the medical record. RN 1 confirmed these omissions during a review of the resident's medical record. For Resident 46, the facility did not assess the risk of entrapment or attempt alternatives before using side rails, nor did they inform the responsible party about the use of side rails. The resident had a physician's order for bilateral padded side rails due to medical necessity for seizures, but there was no documented evidence of an assessment for bed zone entrapment. RN 5 and the Medical Record Assistant were unable to locate documentation for the assessment or informed consent, acknowledging that these were not completed. These failures had the potential to place the residents at risk for entrapment.
Improper Medication Administration via GT and Inadequate Bowel Pattern Check
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident, specifically in the administration of medications via a gastrostomy tube (GT). The policy required medications to be administered by gravity, but during an observation, a Licensed Vocational Nurse (LVN) was seen using a syringe to push a crushed docusate sodium tablet through the resident's GT, contrary to the policy. This deviation from the policy was acknowledged by the LVN during a follow-up interview. Additionally, the facility did not ensure that the resident's bowel pattern was checked for loose stools or diarrhea before administering the stool softener, docusate sodium. The resident had a documented history of loose stools/diarrhea for several weeks, yet the LVN did not review this information before administering the medication. The LVN relied on a verbal endorsement from the previous nurse, which inaccurately reported the resident's bowel condition. This oversight was confirmed during an interview with the LVN, who admitted the medication should not have been given under the circumstances.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to adequately monitor a resident's blood pressure and heart rate before administering prescribed medications, leading to a deficiency. Resident 73, who was on amlodipine and losartan for hypertension, had specific physician orders to hold the medications if the systolic blood pressure was less than 110 mmHg or if the heart rate was less than 60 beats per minute. However, from November 1 to November 19, 2024, there was no documented evidence that the licensed staff checked these vital signs before administering the medications at the prescribed times of 0900 and 1700 hours. This oversight was confirmed during an interview and concurrent medical record review with RN 5 on November 20, 2024.
Failure to Ensure Residents are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, as evidenced by the prescription practices for psychotropic drugs. Resident 124 was prescribed zolpidem, a hypnotic medication, on an as-needed basis for insomnia without a 14-day stop date, contrary to the facility's policy. This oversight was confirmed during interviews with RN 2 and the Director of Nursing (DON), who acknowledged the absence of a stop date for the medication. Resident 86 was prescribed quetiapine fumarate, an antipsychotic medication, for intermittent explosive disorder without a documented diagnosis or clinical rationale at the time of prescription. The resident's medical records did not show a diagnosis of psychosis or intermittent explosive disorder prior to the continuation of the medication. This was verified by RN 1 and the Assistant Director of Nursing (ADON), who confirmed the lack of documentation supporting the prescription of quetiapine fumarate before the resident was seen by a psychiatrist.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and management of medications and supplies in one of its medication rooms and several medication carts. In Medication Room A, multiple expired medications were found, including acetaminophen, vitamin B6, and normal saline vials. This oversight had the potential to lead to the unsafe administration of medications. Additionally, the facility did not prevent the storage of antifungal cream at a resident's bedside, which could have allowed unauthorized access to the medication. The resident in question had moderate cognitive impairment and was not assessed as a candidate for self-administration of medications, and there was no physician's order for the cream. Medication carts also exhibited significant deficiencies. Medication Cart D contained a mix of external and internal medications alongside bleach germicidal wipes, posing a risk of unsafe administration. Medication Cart E was found to have expired vials of normal saline, and Medication Cart F had germicidal wipes, adult washcloths, and Povidone-Iodine swabsticks stored with nutritional supplements, risking cross-contamination. Additionally, albuterol inhalation solutions were not stored according to the manufacturer's recommendations, as they were found outside their foil pouches. The facility's procedures for the disposal of controlled medications were not followed correctly. The Director of Nursing (DON) did not sign the narcotic disposition log when controlled medications were disposed of, which could lead to drug diversion. Furthermore, several medication carts contained expired supplies, such as alcohol-free liquid skin prep, wound dressing supplies, and povidone-iodine prep pads. These expired items were not discarded as required, and opened sterile gloves were found, which compromised their sterility. The facility's failure to adhere to its policies and procedures for medication storage and disposal was verified by the DON and other staff members.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 6,144 citations issued within 25 miles in the last 12 months — including the 21 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 Buena Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Healthcare Center Of Orange County | 0.6 mi | ★★★★★ | 10 | 0 |
| Anaheim Terrace Care Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Anaheim Crest Nursing Center | 1 mi | ★★★★★ | 30 | 0 |
| West Anaheim Medical Center D/p Snf | 1 mi | ★★★★★ | 16 | 0 |
| Anaheim Healthcare Center, Llc | 1.1 mi | ★★★★★ | 3 | 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.