Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Casa Bonita Convalescent Hospital during CMS and state inspections, most recent first.
A resident with dementia, weakness, obesity, and high fall risk was not given the documented two-person assist during peri-care and bed mobility, and the resident slid from the bed during toileting hygiene, sustaining a displaced femoral neck fracture and being transferred to the hospital. In a separate fall-prevention issue, a second resident’s care plan called for floor mats under the FSP, but none were in place despite staff confirming they should have been used.
Failure to Rotate Insulin Sites and Give Medications on Time: The facility did not follow a resident’s insulin order and CP directing staff to rotate injection sites, and insulin was repeatedly documented as given in the abdomen without site rotation. The facility also gave another resident’s scheduled morning meds outside the ordered time window, despite the DON stating meds should be administered within one hour before or after the scheduled time and that timing can affect effectiveness.
Undated Frozen Food in Kitchen 1: Seven packages of frozen patties were found in Kitchen 1 without an expiration or use-by date. The DS stated labeling is important to maintain food quality, and the DON stated stored food should have expiration or use-by dates so it remains fresh and safe for residents. The facility policy required food items in dry storage and refrigerator/freezer areas to be dated and labeled.
Infection control practices were not followed for three residents with contact precautions or EBP. A trash can full of used PPE was left beside one resident’s bed, a RT suctioning another resident’s tracheostomy did not wear a face shield, and an LVN administering meds via a G-tube for a resident on EBP did not wear a gown. The residents had significant cognitive and functional impairment, and staff interviews confirmed the expected PPE and trash placement practices.
A resident received Lexapro without a documented clinical diagnosis of depression or clear indication for the psychotropic medication. The MDS showed no depressive symptoms and no active depression diagnosis, progress notes did not document sadness, and staff interviews described the resident as calm, outgoing, and feeling fine. RN and DON review of the record noted Lexapro had originally been used for anxiety, while the later order listed depression manifested by verbalization of sadness, which was not supported in the chart.
Failure to Implement Fall-Prevention Care Plan: A resident with a history of falls, muscle weakness, difficulty walking, and mild cognitive impairment had a care plan that included floor mats as a fall intervention, but RN observation confirmed the mats were missing from both sides of the bed. The DON stated care plans direct nursing care and must be specific to the resident, while the facility policy called for appropriate interventions such as a low bed with floor mat.
Failure to Provide Oral Care and Grooming Assistance: A resident with Alzheimer’s disease, dysphagia, and severe cognitive impairment was dependent for ADLs and had a care plan for assistance with ADLs and oral care BID. Surveyors observed the resident lying in bed with light brownish sputum drooling from the mouth during multiple observations, and staff interviews confirmed oral care is part of ADL and grooming.
Delayed refill of furosemide: A resident with CHF, acute pulmonary edema, and acute respiratory failure with hypoxia missed several doses of ordered furosemide because the facility was waiting on a pharmacy refill. RN staff stated there was no documentation explaining the delay, and the DON stated meds should be refilled when 4 to 5 days remain to ensure availability.
A resident with Alzheimer's disease and severely impaired cognition did not have a call light within reach when needing to use the bathroom. The resident stated not knowing where the call light was, and it was found on the floor on the opposite side of the resident. Facility policy required an accessible call system from the bed, toileting/bathing areas, and the floor.
A resident with a history of impulsive behavior and multiple falls was not provided with a resident-centered fall prevention plan, and the facility did not monitor or document the effectiveness of interventions. Despite repeated incidents and known high fall risk, only standard measures such as bed alarms and floor mats were used, without addressing the underlying causes of the resident's behavior. The resident sustained serious injuries after another fall, highlighting the facility's failure to individualize care and assess intervention effectiveness.
Two residents at high risk for pressure injuries were found with low air loss mattresses set incorrectly, contrary to physician orders and facility policy. One resident with quadriplegia had a mattress set higher than ordered, and another with a stage 4 pressure ulcer had a mattress set far above their actual weight. Staff interviews and record reviews confirmed the settings were not properly adjusted or monitored, leading to a failure in pressure ulcer prevention protocols.
Two residents received antibiotics without proper screening or documentation, as the facility failed to use the correct surveillance forms and did not follow established protocols for monitoring antibiotic use. The Infection Control Nurse acknowledged missing required reviews and using incorrect forms, resulting in antibiotics being administered without confirming the presence of true infections.
Two residents were not treated with dignity during meals: one with hemiplegia was left without a clothing protector, resulting in food and drink spills on her body and bedding, while another was fed by a nurse standing over her rather than sitting at eye level, making her feel rushed and uncomfortable. Staff and policy confirmed that these actions did not meet expectations for promoting resident dignity during care.
A resident with multiple complex conditions, including diabetes and severe cognitive impairment, experienced consistently high blood glucose levels and was transferred to a hospital for uncontrolled hyperglycemia. Despite facility policy requiring Interdisciplinary Team (IDT) review for significant changes in condition, staff confirmed that no IDT meeting or care plan revision was documented to address the resident's ongoing hyperglycemia.
A resident with multiple chronic conditions and moderate cognitive impairment was given a time-release antibiotic capsule that was improperly opened and mixed with applesauce by an LVN, contrary to facility policy and without pharmacist verification. This altered the medication's intended delivery, as confirmed by interviews and record review.
A CNA did not wear a gown while removing soiled linens from a resident with severe cognitive impairment and multiple medical conditions who was under Enhanced Barrier Precautions (EBP). Despite clear signage and an active EBP order, the CNA carried the soiled linens into the hallway without appropriate PPE, contrary to facility policy and infection control protocols.
A resident with cognitive impairments and multiple health conditions was mistakenly given another resident's unlabeled dentures, posing an infection risk. The dentures were found in a denture cup at the resident's bedside without proper labeling, contrary to the facility's infection control policies.
The facility failed to inform and provide written information about Advance Directives to several residents or their legal representatives, resulting in a lack of documentation in their medical records. This deficiency affected residents with severe cognitive impairments, preventing the facility from respecting their medical care preferences.
The facility failed to conduct comprehensive assessments for two residents, resulting in discrepancies between their medical records and care plans. One resident with dementia and anxiety received lorazepam, but the MDS did not reflect the anxiety disorder. Another resident was prescribed Ativan for anxiety, yet the MDS did not indicate anxiety or medication use. These inaccuracies were confirmed during reviews with nursing staff.
The facility failed to ensure proper management of GT feedings for three residents. A resident's head of bed was not elevated as required, increasing aspiration risk. Two residents experienced prolonged GT pump alarms without timely staff response, risking nutritional intake and tube complications. Staff interviews confirmed the importance of adhering to facility policies on GT feeding safety.
The facility failed to monitor and document the use of psychotropic medications for three residents. A resident on duloxetine did not have side effects monitored, another on PRN Ativan lacked documented rationale for extended use, and a third had a PRN Lorazepam order extended without proper documentation, all contrary to facility policy.
The facility failed to serve milk/mocha mix at the required temperature of 40 degrees Fahrenheit or lower, as per policy. During a kitchen observation, three glasses of milk were found to be above the safe temperature limit, with readings of 42 F, 44 F, and 51 F. Staff interviews confirmed the importance of maintaining temperatures below 41 F to prevent spoilage and bacterial growth.
A facility failed to develop and implement a resident-centered care plan for a resident on Depakote, with interventions for side effects not documented or implemented. The care plan inaccurately listed allergies, including insulin, despite active insulin orders. The DON stated interventions were unnecessary per the Facility Consultant Pharmacist, and the MDS Coordinator noted the care plan was not individualized.
A resident with severe dementia and communication difficulties did not receive necessary care when a CNA failed to use a communication board, as required by the facility's policy. The resident, who sometimes spoke a different language, was not effectively communicated with, leading to potential unmet needs.
A resident at high risk for pressure ulcers was found lying on a low air loss (LAL) mattress with multiple layers of material, including a sling, which contradicted facility policy. The CNA responsible left the sling under the resident, intending to use it again, but this practice was against guidelines. The DON confirmed the sling should have been removed to ensure the mattress's effectiveness in preventing pressure injuries.
A resident with limited ROM did not receive necessary rehabilitation services to maintain or prevent further decline in ROM. Despite recommendations for splints and passive ROM exercises, the facility failed to follow up on an occupational therapist's recommendation for evaluation and treatment. The resident's joint mobility screening showed a decline, but no physician's order for therapy was obtained, and the resident did not receive further occupational therapy.
A resident with respiratory failure and tracheostomy status did not receive the correct oxygen flow rate as per the physician's order, which was set at 2 LPM. Observations revealed the flow rate was below 1 LPM, contrary to the care plan and facility policy. Interviews with staff confirmed the importance of maintaining the correct flow rate to prevent respiratory distress.
A resident with multiple health issues, including impaired vision, did not receive eye drop medication properly due to a nurse's failure to follow the facility's policy. The nurse administered the drops consecutively without waiting the required five minutes between applications, as confirmed by the DON. This oversight could have affected the medication's effectiveness.
A facility failed to identify irregularities in the monthly Medication Regimen Review for a resident on psychotropic medications. The Consultant Pharmacist did not report inadequate monitoring of duloxetine, used for depression, potentially affecting the resident's well-being. Despite the administration of duloxetine, there was no documented evidence of side effect monitoring, as confirmed by staff interviews.
A resident with spinal stenosis, post laminectomy syndrome, and type 2 diabetes mellitus was not provided a snack at night despite requesting one, as per the facility's policy. Interviews revealed that the facility sometimes ran out of snacks, and the Dietary Supervisor was informed of the shortage. The resident's care plan indicated snacks should be offered, but this was not followed, resulting in a deficiency.
A Registered Dietician in the kitchen was observed without a beard cover while preparing food, contrary to the facility's sanitation policy. The RD's beard was partially exposed despite wearing a surgical mask, which could lead to food contamination. Interviews confirmed the requirement for beard nets, aligning with the facility's infection control policy.
A facility failed to implement Enhanced Standard Precautions (ESP) for a resident with a gastrostomy, leading to a CNA not wearing a gown during high-contact care. Staff interviews revealed a misunderstanding of the ESP policy, which requires gown and glove use for residents with indwelling devices to prevent infection transmission.
A resident with multiple diagnoses, including hemiplegia and respiratory failure, was not readmitted to the LTC facility after hospitalization due to a positive test for Candid Auris. Despite having an available room, the facility did not prepare an isolation room, leading to the resident overstaying at the hospital for 10 days. The facility's policies prioritize readmission, but the resident was not accommodated as required.
Failure to Provide Required Two-Person Assistance and Floor Mats
Penalty
Summary
The facility failed to ensure a safe environment to prevent a fall for Resident 106 by not providing the level of assistance documented in the resident’s assessments and therapy notes during toileting hygiene and bed mobility. Resident 106 had diagnoses including generalized muscle weakness, dementia, and obesity, and was identified as having impaired cognition, being dependent on staff for toileting hygiene, and being at high risk for falls due to intermittent confusion, being bedbound, and incontinence. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the PT encounter note indicated the resident was confused and required maximum assistance with two-person help for bed mobility. On 7/4/2026, while CNA 5 was performing peri-care, Resident 106 slid out of bed and fell to the floor. The change of condition/SBAR documented that the resident slid out of the right side of the bed with the legs leading first, and CNA 5 stated the resident was too heavy to hold when the resident began to slide. CNA 5 reported standing on the resident’s left side, moving the resident’s left arm across the chest, and attempting to tuck an adult brief under the resident when the resident slipped off the bed. The resident sustained discoloration under the chin and on the right knee, and radiology later showed a mild displaced right femoral neck fracture. EMS arrived and transferred the resident to GACH 1. Interviews with the TN, DOR, CNA 6, and DSD indicated that Resident 106 could not turn independently and required two-person assistance for peri-care and bed mobility. The DOR stated the recommendation to nursing staff was based on the resident’s performance during therapy and that two-person assist was safer for both staff and the resident. The facility’s policy on Safety and Supervision of Residents stated resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The deficiency also included Resident 10, whose falling star care plan identified floor mats as an intervention after a prior fall, but on 7/9/2026 no floor mats were in place on either side of the bed despite the care plan and facility falling star program policy indicating floor mats should be used for residents at risk for falls.
Failure to Rotate Insulin Sites and Administer Medications at Prescribed Times
Penalty
Summary
The facility failed to follow a physician order and the care plan for a resident with diabetes, long-term insulin use, and chronic respiratory failure by not rotating insulin injection sites. The resident’s care plan, dated 6/10/2025, identified the resident as at risk for hypoglycemia and hyperglycemia and directed staff to rotate sites when injecting insulin. The physician order for insulin, dated 5/9/2026, also indicated to rotate injection sites. Review of the resident’s records showed insulin injections were documented on the abdomen on 7/1/2026, 7/2/2026, and 7/3/2026 at 12 AM, 6 AM, and 12 PM. During interview and record review, LVN 1 stated the MAR did not indicate site rotation for insulin administration and explained that rotating injection sites is important to prevent irritation or hardening of the skin and for better medication absorption. The DON also stated that rotation of injection sites was important for better absorption and to decrease the risk of hardening of the site. The facility also failed to ensure another resident’s medications were administered within one hour before or after the prescribed time. That resident had diagnoses including pneumonia, dysphagia, and gastrostomy, and was moderately cognitively impaired and dependent for bathing and toileting. LVN 4 stated the resident’s morning medications were due at 9 AM but were given at approximately 7:30 AM, and stated medications due at 9 AM could be given between 8 AM and 10 AM. The MAR showed multiple medications scheduled for 9 AM, including aspirin, enoxaparin, folic acid, polyethylene glycol, vitamin C, baclofen, insulin glargine, docusate sodium, and senna. The DON stated the facility had a policy to give medications one hour before or one hour after the scheduled time and that timing could affect medication effectiveness.
Undated Frozen Food in Kitchen 1
Penalty
Summary
Sanitary conditions were not maintained in Kitchen 1 when, during an initial tour and concurrent interview with the Dietary Supervisor, seven packages of round, light tan, grid-patterned patties were observed in the freezer without an expiration date or use-by-date. The Dietary Supervisor later stated that labeling food with use-by-dates was important to ensure food did not lose texture or flavor and that food could be stale if eaten after the use-by-date. The Director of Nursing stated that stored food should have expiration or use-by-dates to ensure food remained fresh and safe for residents to eat. Review of the facility's Dating and Labeling policy indicated that food items should be properly covered, dated, and labeled in dry storage and refrigerator/freezer areas, and that no food item expired or beyond the best buy date should be kept in stock.
Infection Control Practices Not Followed for Residents on Isolation and Barrier Precautions
Penalty
Summary
Infection control practices were not implemented for three residents with isolation or barrier precautions in place. For one resident with contact precautions, a tall gray trash can full of used PPE gowns was observed next to the bedside during a room observation, and staff stated the trash should have been kept away from the bed and closer to the door or sink area. The resident had severe cognitive impairment, was dependent for activities of daily living, and had diagnoses including dependence on a respirator and tracheostomy care needs. For a second resident who was a carrier of CRAB and on contact isolation, a respiratory therapist was observed suctioning the resident’s tracheostomy tube without wearing a face shield. The resident had severe cognitive impairment, was dependent for oral and toilet hygiene and dressing, and had orders for suctioning and contact isolation for CRAB in sputum. Staff interviews stated that face shields were needed during suctioning and oral care because sputum and saliva could splash and spread infection. For a third resident on Enhanced Barrier Precautions, a nurse administered medications via the resident’s G-tube without wearing a gown. The resident had diagnoses including pneumonia, dysphagia, and gastrostomy, was moderately cognitively impaired, and was dependent for bathing and toileting. The resident’s care plan and the facility’s EBP policy identified gown and glove use for high-contact care activities, including feeding tube care, and the DON stated gowns were needed during G-tube medication administration because of possible splashing of bodily fluids.
Unclear indication for Lexapro without documented depression diagnosis
Penalty
Summary
The facility failed to ensure there was a documented clinical diagnosis of depression and a specific indication for Lexapro before the medication was administered to one resident. The resident’s face sheet showed multiple diagnoses including ESRD and anxiety disorder, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS dated 5/26/2026 indicated the resident’s cognitive skills for daily decision making were intact, there were no symptoms of little interest or pleasure in doing things or feeling down, depressed, or hopeless, and the resident had no active diagnosis of depression but was taking an antidepressant medication. Progress notes from 5/1/2026 through 6/21/2026 did not indicate the resident was feeling sad or verbalized sadness. The order summary showed Lexapro 5 mg at bedtime was ordered for depression manifested by verbalization of sadness, but RN 2 stated Lexapro had originally been ordered for anxiety as manifested by restlessness and trichotillomania, and that the resident’s records did not show a diagnosis of depression. During interviews, the resident was observed calm, alert, and stating feeling fine or very well, and CNA 4 stated the resident was outgoing and had not expressed feeling depressed. The DON reviewed the order and stated verbalization of sadness alone was not an indication for depression, and that clarifying the Lexapro order with the physician was important because the medication could have been unnecessary.
Failure to Implement Fall-Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident 10 when floor mats were missing from either side of the resident’s bed on 7/9/2026, despite the resident’s Falling Star Program care plan, initiated on 5/8/2026, identifying floor mats as an intervention. Resident 10 was admitted with diagnoses including muscle weakness, difficulty in walking, and history of falling. The resident’s history and physical dated 5/7/2026 indicated the resident had the capacity to understand and make decisions. Resident 10 had a witnessed fall on 5/8/2026 at 12:35 PM, and the rehab fall risk assessment identified a floor mat as a useful intervention after the fall. The care plan for the Falling Star Program indicated the resident was at risk for falls and included floor mats as an intervention. The MDS dated 5/12/2026 indicated mild cognitive impairment and that the resident required maximal assistance for toileting hygiene, shower/bathing, and lower body dressing. During observation and interview on 7/9/2026, RN 3 confirmed there were no floor mats placed on either side of the bed and stated there should be floor mats based on the current nursing interventions in the care plan.
Failure to Provide Oral Care and Grooming Assistance
Penalty
Summary
The facility failed to ensure Resident 24 received the necessary services to maintain personal grooming and oral hygiene as indicated in the facility’s ADL policy. Resident 24 was admitted and later readmitted with diagnoses including Alzheimer’s disease and dysphagia. The MDS dated 6/25/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident was dependent with ADLs. The H&P dated 6/30/2026 stated the resident did not have the capacity to understand and make decisions. The care plan, initiated 5/24/2023 and revised 10/07/2024, identified self-care deficits and included assisting with ADLs as needed and dental/oral care twice daily and as needed. During an observation on 7/6/2026 at 10:37 AM, Resident 24 was lying in bed with light brownish sputum drooling from the left side of the mouth, and the room had EBP signage posted outside. A female staff member entered the room with a double hamper at 10:55 AM and exited at 11:04 AM, while the resident still had light brownish sputum drooling from the mouth. During a concurrent observation and interview at 12:18 PM, RN 1 observed the same condition and stated oral care was important and part of grooming and care for the resident to look presentable. CNA 3 later stated oral care was part of ADL and important to prevent aspiration and breakdown of the gums. The facility’s ADL policy stated residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, personal and oral hygiene.
Delayed refill of furosemide
Penalty
Summary
The facility failed to ensure furosemide oral tablets were refilled in a timely manner for one resident. The resident was admitted and later readmitted with diagnoses including acute respiratory failure with hypoxia, acute pulmonary edema, and acute on chronic diastolic congestive heart failure. The resident’s MDS dated 4/9/2026 indicated intact cognition and dependence on staff for bathing and toileting. The resident had an active order for furosemide 20 mg by mouth daily for heart failure, with instructions to hold if systolic blood pressure was less than 100, and the care plan identified the resident as at risk for respiratory distress with increased respiration and visible labored breathing, with an intervention to administer furosemide as ordered. During review of the MAR, the resident did not receive furosemide on 7/3/2026, 7/4/2026, and 7/6/2026. RN 2 stated the medication was not given because the facility was waiting for the pharmacy refill and that it was not clear why the medication had not been filled earlier because there was no documentation, although refills typically took only one day to be delivered. RN 2 also stated nurses should document when communicating with pharmacy staff. The DON stated nursing was supposed to refill medications when there were four to five days left to ensure availability, and that the resident should have had the furosemide available. The facility policy stated repeat medications were to be reordered five days in advance of need to assure an adequate supply was on hand.
Call Light Not Accessible to Resident
Penalty
Summary
A working call system was not available within reach for one resident in the bathroom and bathing area. During observation, the resident was sitting on the edge of the bed with feet on the floor and stated a need to go to the bathroom but did not know where the call light was located. The call light was found on the floor on the opposite side of the resident and was not accessible at the time of the observation. The resident involved had a history of Alzheimer's disease, unspecified mood disorder, history of falling, syncope and collapse, and major depressive disorder. The resident's H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated cognition was severely impaired. During interview, an RN stated the importance of the call light being accessible was for residents to call for staff help. Facility policy stated each resident is to have a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor.
Failure to Implement Resident-Centered Fall Prevention and Monitor Effectiveness
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident with a known history of impulsive behavior and repeated attempts to get out of bed unassisted. Despite being identified as a high fall risk with multiple diagnoses, including encephalopathy and type 2 diabetes, the resident experienced several falls over a period of months. The care plan interventions primarily consisted of standard fall prevention measures such as low bed, floor mats, bed alarms, and placement near the nurse's station, but did not include a resident-centered approach or address the specific causative factors of the resident's behavior as required by the facility's policy. The facility did not consistently monitor or document the effectiveness of the fall prevention interventions. Although the care plan called for assessment and reduction of behavioral triggers, staff interviews and record reviews revealed that the facility did not investigate or document the underlying causes of the resident's repeated attempts to self-transfer. The interdisciplinary team conferences following each fall did not result in new or individualized interventions, and the facility continued to rely on the same standard measures despite ongoing incidents. Staff acknowledged the resident's impulsiveness and need for close monitoring, but the facility did not utilize sitters or other enhanced supervision strategies. On the date of the most serious incident, the resident was found on the floor mat after the bed alarm sounded, having sustained significant injuries including fractures to both hips. Documentation indicated that frequent rounding was being performed, but there was no evidence of a comprehensive evaluation of the effectiveness of interventions or of any changes made to address the resident's persistent fall risk. The facility's failure to implement a resident-centered fall prevention plan, monitor the response to interventions, and assess causative factors contributed to the resident's repeated falls and resulting injuries.
Incorrect Low Air Loss Mattress Settings for High-Risk Residents
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs), which are pressure-reducing devices, were set at the correct settings for two residents at high risk for pressure injuries. For one resident with functional quadriplegia and severely impaired cognition, the LALM was observed to be set at 200, despite a physician's order specifying a setting of 160 based on the resident's weight. Staff interviews confirmed that the setting was incorrect and should have been checked during daily rounds, but the discrepancy was not identified or corrected at the time of observation. Another resident, who was dependent for all activities of daily living and had a history of chronic respiratory failure and a stage 4 sacral pressure ulcer, was found lying on a LALM set at 400 lbs, while the resident's actual weight was 107 lbs and the physician's order specified a setting of 80. Staff interviews indicated that the correct mattress setting is essential for effective pressure redistribution and prevention of further skin breakdown, and that the mattress should be set according to the resident's actual weight as per facility policy and manufacturer instructions. Record reviews, staff interviews, and direct observations confirmed that the facility did not follow its own policy and physician orders regarding the adjustment of LALM settings based on resident weight. The failure to maintain correct mattress settings was observed for both residents, and staff were unable to provide an explanation for the discrepancies at the time of the survey.
Failure to Implement Antibiotic Stewardship Program and Proper Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two of five sampled residents, resulting in the improper monitoring and documentation of antibiotic use. For one resident with vascular dementia and generalized weakness, a change in condition was noted with greenish vaginal discharge but no pain, discomfort, or fever. Despite these findings and a urine culture report indicating that antibiotic therapy was not recommended without localized urinary tract symptoms, the resident was prescribed and administered Diflucan. The Infection Control Nurse (ICN) acknowledged that the wrong surveillance form was used and that the appropriate McGreer's UTI criteria should have been applied to determine the necessity of antibiotics, but this review was missed for the month in question. Another resident with neuralgia and generalized weakness was prescribed Azithromycin for a tooth infection. The ICN stated that the incorrect antibiotic surveillance form was used for this resident as well, and the proper screening for skin/mucosal infection was not completed. The ICN did not follow up to verify if the correct antibiotic screening was performed, resulting in the resident receiving antibiotics without confirmation that the criteria for a true infection were met. Facility policy required the use of approved antibiotic surveillance tracking forms and regular review of antibiotic usage patterns by the leadership team. The Infection Preventionist was responsible for implementing the infection prevention and control program, including the collection and review of antibiotic use data. However, these protocols were not followed, and the required documentation and monitoring were not completed for the residents in question.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity during mealtimes. One resident with hemiplegia and hemiparesis, who was unable to use her left side and had severely impaired cognitive skills, was observed eating breakfast in bed without a clothing protector. This resulted in food and drink spilling onto her chest, neck, gown, tray, bedside table, and comforter. Staff interviews confirmed that a towel or similar item should have been placed to protect the resident and maintain her dignity during meals, but this was not done at the time of observation. Another resident, who had dementia, diabetes, and severe protein-calorie malnutrition, required substantial assistance with activities of daily living and was dependent for mobility. During a lunch meal, a treatment nurse was observed standing and leaning over the resident while providing feeding assistance, rather than sitting at eye level. The resident reported feeling rushed and uncomfortable when staff stood over her during meals, expressing a preference for staff to sit beside her, which made her feel more at ease. The nurse later acknowledged that sitting at eye level would have promoted dignity and comfort for the resident. Facility policy and staff interviews confirmed that the expectation was to uphold resident dignity during all aspects of care, including meal assistance. The policies reviewed emphasized providing a dignified dining experience and treating all residents with kindness, respect, and dignity. However, the observed actions did not align with these expectations, resulting in a failure to honor the residents' rights to a dignified existence and self-determination during mealtimes.
Failure to Conduct IDT Review for Persistent Hyperglycemia
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice by not conducting an Interdisciplinary Team (IDT) review for a resident who experienced continuous episodes of hyperglycemia. The resident, who had multiple complex diagnoses including type 2 diabetes mellitus, dementia, and a feeding tube, was admitted and later readmitted to the facility. Medical records indicated that the resident's cognitive status was severely impaired and that she was unable to make her own decisions. Blood glucose monitoring showed consistently high levels ranging from 306 mg/dL to 500 mg/dL over a ten-day period. Despite these findings and a subsequent transfer to an acute care hospital for uncontrolled hyperglycemia, there was no documentation of an IDT meeting to address the resident's condition. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that no IDT documentation existed for the resident's episodes of hyperglycemia. The facility's policy and procedure required that care plans be reviewed and revised by the IDT after each assessment or significant change in condition, including issues related to diagnosis or health condition. The lack of an IDT review and care plan revision in response to the resident's persistent hyperglycemia constituted a failure to follow established protocols and professional standards of care.
Significant Medication Error Due to Improper Administration of Time-Release Capsule
Penalty
Summary
A deficiency occurred when facility staff failed to ensure a resident was free from significant medication errors. Specifically, a Licensed Vocational Nurse (LVN) was observed opening a Macrobid (nitrofurantoin macrocrystals) 100 mg oral capsule, pouring its contents into a medication cup, and mixing it with applesauce prior to administration. This action disrupted the time-release mechanism of the medication, which was intended to be delivered in a specific manner for therapeutic effectiveness. The LVN acknowledged that opening capsules should only be done after verification with a pharmacist, as some capsules are not meant to be opened due to potential changes in drug efficacy and safety. The resident involved had multiple diagnoses, including rheumatoid arthritis, diabetes mellitus, and encephalopathy, and was assessed as having moderately impaired cognition. The resident required assistance with activities of daily living and supervision with mobility. The medication order for Macrobid specified administration by mouth, but did not indicate that the capsule should be opened or mixed with food. The Medication Administration Record confirmed that the resident received the medication in this altered form. Interviews with the LVN and the Director of Nursing (DON) confirmed that facility policy required clarification with a pharmacist before altering any capsule medication, especially antibiotics that are often time-released. The DON emphasized the importance of maintaining the intended formulation to ensure proper absorption and effectiveness. Review of facility policy and job descriptions further supported that medications were to be administered as prescribed and in accordance with regulatory guidelines.
Failure to Follow Enhanced Barrier Precautions During Linen Handling
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow Enhanced Barrier Precautions (EBP) when handling soiled linens for a resident with multiple diagnoses, including peripheral vascular disease, COPD, and cellulitis. The resident had severe cognitive impairment and required partial to moderate assistance with activities of daily living and mobility. Despite signage indicating EBP outside the resident's room and an active order for EBP, the CNA was observed removing soiled linen from the resident's bed and carrying it into the hallway without wearing a gown, as required by facility policy and EBP protocols. Interviews with the CNA and the Infection Preventionist confirmed that staff were expected to wear gloves and gowns during high-contact care activities, such as changing soiled linens, to prevent the spread of infection. The facility's policy specified that gowns and gloves must be used during these activities, but the CNA did not adhere to these requirements during the observed incident. This lapse in infection control practices constituted a failure to maintain the facility's infection prevention and control program.
Infection Control Breach Due to Misidentified Dentures
Penalty
Summary
The facility failed to maintain and implement its Infection Control Program, leading to a potential risk of infection for a resident. The incident involved placing another resident's dentures into the mouth of a resident who was admitted with diagnoses including a urinary tract infection, dementia, and type 2 diabetes mellitus. The resident was severely impaired in cognitive skills and required substantial assistance for daily activities. The dentures, which were not labeled, were mistakenly identified as belonging to the resident and were placed in their mouth by a dentist. Interviews with family members and staff revealed that the dentures were found in a denture cup at the resident's bedside, but they were not labeled with any identifying information. The facility's policy required dentures to be stored in labeled containers to prevent such mix-ups. The Infection Preventionist confirmed that using the wrong dentures posed a risk of infection. The facility's policies on denture storage and infection control were not followed, leading to this deficiency.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that five of nine sampled residents and/or their legal representatives were informed and provided with written information about Advance Directives (AD). This deficiency was identified through interviews and record reviews, revealing that residents or their responsible parties were not adequately informed about their rights to formulate an AD, which is crucial for making medical care decisions when residents are unable to communicate their wishes. For Resident 41, the admission record indicated multiple diagnoses, including dementia and type 2 diabetes mellitus, and showed that the resident did not have the capacity to make decisions. The responsible party did not sign the Advance Directive Acknowledgment (ADA) form, and there was no documented evidence that information regarding AD was provided. Similarly, Resident 30, who had severe cognitive impairments, did not have an ADA or AD in their chart, and the facility staff acknowledged the absence of these documents, which are essential for respecting the resident's wishes. Residents 25 and 53 also lacked proper documentation of ADs in their medical records. Both residents had severe cognitive impairments and were dependent on others for decision-making. The facility's policy required that residents or their representatives be provided with written information about their rights concerning ADs, but this was not consistently implemented. The absence of ADs in the residents' charts meant that the facility staff could not be aware of or respect the residents' medical care preferences, especially in emergencies.
Inaccurate Resident Assessments Lead to Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure comprehensive assessments of disease diagnoses, health conditions, and medications for two residents, leading to potential inaccuracies in their care plans. Resident 27 was admitted with multiple diagnoses, including dementia and generalized anxiety disorder, but the Minimum Data Set (MDS) did not reflect the anxiety disorder, despite the resident receiving lorazepam for anxiety-related symptoms. The inconsistency between the MDS and the physician's orders highlighted a lack of accurate assessment, which was confirmed during a review with a registered nurse. Similarly, Resident 20, admitted with dementia, was prescribed Ativan for anxiety, yet the MDS did not indicate the presence of anxiety or the use of anti-anxiety medication. The resident received Ativan multiple times over several days, but the MDS assessments failed to capture this information. The Director of Nursing acknowledged the importance of thorough assessments, including physical evaluations and communication with staff and family, to ensure accurate MDS completion and appropriate care planning.
Deficiencies in GT Feeding Management
Penalty
Summary
The facility failed to provide appropriate treatment and services for three residents receiving gastrostomy tube (GT) feedings. Resident 36's head of bed (HOB) was not elevated to the required 30-45 degrees during GT feedings, as per the facility's policy and physician's orders, which is crucial to prevent aspiration. Observations revealed that Resident 36's HOB was only elevated to 20-25 degrees, and staff interviews confirmed the necessity of maintaining the correct elevation to avoid aspiration risks. For Residents 25 and 252, the facility did not respond timely to the GT pump alarms, which indicated a flow error and potential clogging in the feeding line. Resident 25, who was nonverbal and had multiple diagnoses including cerebral palsy and severe protein-calorie malnutrition, was observed with a beeping GT pump for an extended period. Similarly, Resident 252, who had a history of cerebral infarction and severe cognitive impairment, experienced prolonged GT pump alarms without timely intervention from the staff. The facility's policy on enteral feeding safety precautions and equipment checks was not adhered to, as evidenced by the delayed response to the GT pump alarms for Residents 25 and 252. Staff interviews highlighted the importance of addressing these alarms promptly to ensure the residents received their nutritional intake and to prevent complications such as GT clogging or the need for tube replacement.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents did not receive unnecessary psychotropic medications. For Resident 11, the facility did not monitor the side effects of duloxetine, a psychotropic drug used to treat major depressive disorder, from 5/1/2024 through 5/15/2024. Despite the resident's severe cognitive impairment and frailty, there was no documented evidence of side effect monitoring, which is crucial to prevent adverse effects. Resident 20 was administered Ativan, a medication for anxiety, on a PRN basis without documented rationale for its continuation beyond 14 days. The facility's policy requires that PRN orders for such medications be limited to 14 days unless a healthcare provider evaluates and documents the rationale for extension. However, there was no documentation from the prescribing healthcare provider justifying the extended use of Ativan for Resident 20, who also had severe cognitive impairment. For Resident 96, the facility did not adhere to its policy of limiting PRN orders for Lorazepam to 14 days. The resident's PRN order for Lorazepam was extended to 30 days without documented rationale from the primary care physician. This oversight occurred despite the resident's severe dementia and need for substantial assistance with daily activities. The facility's failure to document the rationale for extending the PRN order contravened its own policy and procedure guidelines.
Improper Milk Temperature in Meal Service
Penalty
Summary
The facility failed to ensure that three out of four sampled glasses of milk/mocha mix were served at the appropriate temperature of 40 degrees Fahrenheit or lower, as required by the facility's policy. During an observation in the facility kitchen, several 8-ounce glasses of milk were prepared on trays for residents' lunch. Upon random selection, three glasses were found to have temperatures exceeding the safe limit: one at 42 F, another at 44 F, and the last at 51 F. This was confirmed during interviews with Kitchen Aid 1 and the Dietary Supervisor, both of whom acknowledged that milk should be kept below 41 F to prevent bacterial growth and spoilage. The facility's policy, updated in March 2024, mandates that cold beverages and desserts be served at no more than 40 degrees F.
Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident, specifically regarding the risk of side effects from the medication Depakote and the resident's allergies. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, generalized anxiety disorder, and bipolar disorder, had severely impaired cognition and was dependent on staff for daily activities. The care plan for Depakote included interventions to monitor for cognitive impairment and other side effects, but these interventions were not documented in the Medication Administration Record (MAR) and were not being implemented. The Director of Nursing stated that these interventions were not needed, as advised by the Facility Consultant Pharmacist, because Depakote is not an antipsychotic medication and typically does not have these side effects. Additionally, the care plan inaccurately listed the resident's allergies, including insulin, despite the resident having active physician orders for insulin medications. The Minimum Data Set Coordinator acknowledged that the care plan was not individualized or person-centered, as evidenced by the inaccurate allergy information and the unimplemented interventions for Depakote. The facility's policy and procedure for comprehensive person-centered care plans require that interventions be derived from a thorough analysis of gathered information and reflect recognized standards of practice, which was not adhered to in this case.
Failure to Use Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident with severe dementia, hypertension, and dysphagia, who was admitted with severe cognitive impairments and required substantial assistance for daily activities. The deficiency occurred when a Certified Nursing Assistant (CNA) did not utilize a communication board to communicate with the resident, as indicated in the facility's policy and procedure for accommodating communication needs. The resident, who sometimes spoke a different language and was confused, was not effectively communicated with, leading to potential unmet needs. Interviews with CNAs revealed that the resident often yelled and did not speak English when confused. One CNA admitted to not using a communication board, which was part of the resident's care plan, and was unaware of its availability. The facility's policy required the use of communication boards with written translations to ensure effective communication with residents. This oversight in following the care plan and facility policy resulted in a deficiency related to the resident's communication needs.
Failure to Prevent Pressure Ulcers Due to Improper Use of LAL Mattress
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of pressure ulcers for a resident identified as being at high risk. The resident, who was dependent on others for daily activities and had severe cognitive impairment, was observed lying on a low air loss (LAL) mattress with multiple layers of material between them and the mattress. This included a flat sheet, chux pad, cloth incontinence pad, adult diaper, and a sling, which contradicted the facility's policy for using LAL mattresses effectively. The certified nursing assistant (CNA) responsible for the resident admitted to leaving the sling under the resident after transferring them back to bed, intending to use it again shortly. However, this practice was against the facility's guidelines, which required the removal of the sling to ensure the LAL mattress could function properly in preventing pressure injuries. The CNA also acknowledged that having more than one sheet would hinder the mattress's effectiveness. The Director of Nursing (DON) confirmed that the sling should have been removed and that the resident should only have been lying on a flat sheet with an adult diaper or a chux pad. The DON and another CNA both recognized that the improper use of the LAL mattress could lead to the development of pressure injuries. The facility's policies and procedures, as well as the CNA job description, emphasized the importance of using appropriate linens and measures to prevent pressure injuries, which were not followed in this instance.
Failure to Provide Necessary Rehabilitation Services for ROM Maintenance
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received necessary rehabilitation services to maintain or prevent further decline in ROM. The resident, who was admitted with multiple diagnoses including dementia, osteoarthritis, and contractures, was discharged from skilled occupational therapy and placed on a Restorative ROM Program. Despite recommendations for the application of splints and passive ROM exercises, the facility did not follow up on the occupational therapist's recommendation for an evaluation and treatment order. The resident's joint mobility screening indicated a decline in ROM, particularly in the left upper extremities, from minimal to moderate loss. However, there was no documented evidence that the nursing staff obtained a physician's order for occupational therapy evaluation or treatment following this decline. Interviews with the Director of Rehabilitation and a registered nurse confirmed that no such order was made, and the resident did not receive occupational therapy in the facility after the initial period. The Director of Nursing acknowledged that nursing staff should consult with the rehabilitation department and obtain new orders if a resident experiences a decline in ROM. The facility's policies and procedures require regular assessments and updates to care plans to prevent deterioration of joint mobility, but these were not adhered to in this case, leading to the deficiency.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 61, who required oxygen therapy. The resident was admitted with multiple diagnoses, including respiratory failure, tracheostomy status, and anoxic brain damage. The care plan for the resident specified interventions such as maintaining an oxygen flow rate of 2 liters per minute (LPM) via a t-bar and monitoring oxygen saturation to keep it above 92%. However, during an observation, it was noted that the oxygen flow rate was below the 1-liter mark, which was not in accordance with the physician's order. Interviews with the Respiratory Therapist Supervisor and a Registered Nurse confirmed the importance of maintaining the correct oxygen flow rate to prevent respiratory distress. The facility's policy on oxygen administration required the proper flow of oxygen to be administered, but this was not adhered to in the case of Resident 61. The deficiency was identified through a review of the resident's records, care plans, and physician orders, which highlighted the discrepancy in the oxygen flow rate being provided.
Improper Administration of Eye Drops to Resident
Penalty
Summary
The facility failed to administer eye drop medication properly to a resident, identified as Resident 49, in accordance with its policy and procedure. Resident 49, who was admitted with multiple diagnoses including ventricular fibrillation, tracheostomy status, and gastrostomy, had a care plan addressing potential alteration in visual function due to eye dryness. The care plan included the administration of Visine Dry Eye Relief Ophthalmic Solution, with a specific order to instill two drops in both eyes three times a day. However, during a medication pass, a Licensed Vocational Nurse (LVN) administered the eye drops consecutively without waiting the required five minutes between applications, as per the facility's policy. The Director of Nursing (DON) confirmed that the facility's policy required a five-minute interval between eye drop applications to ensure optimal absorption and effectiveness. The LVN involved was unaware of this requirement, which was crucial for the resident to receive the full benefits of the medication. The facility's policy, dated 2008, clearly outlined the procedure for safe and accurate administration of ophthalmic solutions, emphasizing the importance of waiting between applications. This oversight had the potential to compromise the effectiveness of the treatment for Resident 49's eye dryness.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that irregularities in the monthly Medication Regimen Review (MRR) were identified for a resident who was on psychotropic medications. The Consultant Pharmacist (FCP) did not identify or report inadequate monitoring of duloxetine, a psychotropic medication used to treat depression, during the MRR conducted from May 14 to May 15, 2024. This oversight had the potential to affect the resident's physical and psychosocial well-being due to the administration of unnecessary psychotropic medications. The resident, admitted on April 27, 2024, had multiple diagnoses including Alzheimer's disease and depression, and was noted to have severe cognitive impairment. Despite the administration of duloxetine from May 1 to May 15, 2024, there was no documented evidence of monitoring for side effects. Interviews with the Registered Nurse and the Director of Nursing confirmed the lack of documentation and emphasized the importance of monitoring side effects to prevent adverse effects. The FCP acknowledged the oversight, stating that monitoring side effects is crucial to ensure appropriate medication dosing without adverse effects.
Failure to Provide Snacks to Resident
Penalty
Summary
The facility failed to provide a snack to a resident, identified as Resident 48, in accordance with its Policy and Procedure titled 'Frequency of Meals.' Resident 48, who was admitted with spinal stenosis, post laminectomy syndrome, and type 2 diabetes mellitus, reported feeling hungry at night and requested a snack from the facility staff. However, the staff did not provide a snack, which was contrary to the facility's policy that nourishing snacks should be available for residents who need or desire additional food between meals. During interviews, a Registered Nurse (RN) acknowledged that sometimes the facility ran out of snacks, and there was an instance when the RN could not provide a snack to Resident 48 during the night shift. The Dietary Supervisor confirmed that the kitchen staff provided snack trays to the facility units for distribution during the evening and night shifts, but nursing staff had informed the supervisor about a shortage of snacks available for residents during the night. The care plan for Resident 48 indicated that snacks should be offered, yet this was not adhered to, leading to the deficiency.
Sanitation Breach in Kitchen Due to Uncovered Beard
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, as observed during a survey. A Registered Dietician (RD) with a visible beard was seen in the kitchen food preparation area without a beard cover, which is against the facility's policy. The RD was observed moving from the cold drinks preparation area to the food assembly tray line while the residents' lunch was being prepared. Although the RD wore a surgical mask, the beard was not fully covered, with parts of it protruding from under the mask. Interviews with the Dietary Supervisor and the RD confirmed that kitchen staff are required to wear a beard net if they have facial hair, to prevent contamination of residents' food. The facility's policy on Sanitation and Infection Control, dated March 2024, mandates that beards and mustaches should be closely trimmed or covered at all times to ensure sanitary conditions. This oversight had the potential to lead to contamination of the food served to residents.
Failure to Implement Enhanced Standard Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control practices, specifically the Enhanced Standard Precautions (ESP), for a resident with multiple medical conditions, including dementia, type 2 diabetes, and a gastrostomy. The resident, who was admitted on 9/29/2020, was dependent on staff for all self-care activities and had severely impaired cognitive skills. During an observation, a Certified Nursing Assistant (CNA) was seen changing the resident's adult brief while wearing gloves but not a gown, contrary to the facility's policy that requires both gown and gloves for high-contact care activities. Interviews with staff revealed a misunderstanding of the ESP policy. The CNA believed that the resident was not on ESP and therefore did not require a gown. However, a Registered Nurse and the Director of Nursing clarified that all residents, especially those with indwelling medical devices like a gastrostomy tube, should be on ESP to prevent infection transmission. The facility's policy mandates the use of gowns and gloves during high-contact activities for residents with wounds or indwelling devices, regardless of MDRO colonization.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident from the General Acute Care Hospital (GACH) after the resident was cleared to return. The resident, who had multiple diagnoses including hemiplegia, respiratory failure, and dysphagia, was initially admitted to the facility and later readmitted with severe cognitive impairment. The resident was dependent on staff for daily activities. After being transferred to the GACH, the resident tested positive for Candid Auris, a multidrug-resistant fungal infection, which required isolation upon return to the facility. The facility's administrator and admissions coordinator indicated that there was an empty room available when the GACH was ready to discharge the resident back to the facility. However, the facility was concerned about the potential spread of C. Auris and did not have an isolation room prepared for the resident. The admissions coordinator acknowledged that the facility could have accommodated the resident's readmission by making room changes, similar to those made previously for another resident. The facility's policy and procedure for readmission and bed-holds state that residents should be given priority for readmission following hospitalization, regardless of payer source, and should be allowed to return to their previous room or the first available bed in a semi-private room. Despite these policies, the facility did not readmit the resident, resulting in the resident overstaying at the GACH for 10 days. The infection preventionist noted that the resident was the fifth case of C. Auris at the facility.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 4,423 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Dimas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woods Health Services | 1.2 mi | ★★★★★ | 25 | 0 |
| Bayshire San Dimas Post-acute | 2.3 mi | ★★★★★ | 17 | 0 |
| Arbor Glen Care Center | 2.9 mi | ★★★★★ | 28 | 0 |
| Claremont Care Center | 2.9 mi | ★★★★★ | 12 | 0 |
| Citrus Heights Health Center | 3.2 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.