Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Casa De Las Campanas during CMS and state inspections, most recent first.
A resident with a history of right femur fracture and muscle weakness, identified as high risk for falls, experienced a fall while attempting to reach a wheelchair without activating the call light. Although new fall prevention interventions were discussed, there was no documentation of these interventions or an updated care plan after the resident returned from the hospital. The DON confirmed the care plan was not revised to reflect the incident or new measures.
A nurse failed to verify a resident's identity and administered medications orally instead of via G-tube as ordered, resulting in the resident choking and requiring emergency intervention. The nurse did not follow facility policy or the five rights of medication administration.
Improper Storage of Medications and Nutritional Supplements: A resident kept three eye drops at the bedside in a paper cup, including one self-administered and one administered by an RN, while the IP and ADON stated a lock box should be used for self-administered meds. In addition, an LPN found expired ibuprofen and Juven in a med room, and expired povidone iodine, Boost, and bisacodyl in the central supply room; staff stated expired meds and supplements should not be kept because they lose potency.
Food Served at Improper Temperature and Poor Palatability: The facility failed to serve meals in a palatable, flavorful manner and at resident-preferred temperatures. Several residents complained that warm food was served cold or lacked flavor, and trayline testing showed temperature drops between service and tray sampling. A resident with a regular diet could not identify a green vegetable on the tray, another resident sent back flavorless spaghetti, and a third resident said the spinach had poor taste and texture. The DM acknowledged the food could taste better and stated palatable, properly tempered food was important to resident enjoyment and weight maintenance.
Food items in the kitchen reach-in refrigerators were found without proper dating and with expired product still present. An opened container of cottage cheese had no open date, sliced cheese had an unreadable date and was not securely wrapped, and sliced peaches with an expired use-by date remained in the refrigerator. The DA and DM stated food items should be labeled, dated, and expired items removed.
Failure to assess a resident’s ability to self-administer eye medications led to a deficiency. The resident, who had diagnoses including hypotension and diabetes, kept multiple eye drops at bedside and reported self-administering some drops while asking staff to administer others. Staff confirmed there was no self-administration assessment, and the resident’s meds were not being managed with the required documentation and secure storage.
Failure to Document and Follow Up on Advance Directives: A resident admitted with COPD and later documented as unable to understand or decide due to dementia had no advance directive in the chart, and the POLST had no advance directive information entered. Record review found no evidence the facility offered or followed up on advance directives, and the SSC stated the resident should have had one documented.
Missing informed consent for psychotropic medications: A resident with dementia and severe cognitive impairment was ordered Quetiapine and Brexpiprazole, but the chart lacked signed informed consent from the RP before the meds were given. The ADON and an LPN confirmed the consents were missing or signed later, and the RP said she did not recall any prior discussion about the purpose, risks, or benefits of the medications.
Failure to provide transfer/discharge and bed-hold notices for a resident who was sent to the ER twice after a fall. The resident had a displaced elbow fracture and a dislocated shoulder, and record review plus staff interviews showed the required written notices were not found for either transfer. Facility policy required written notice of the reason, effective date, location, appeal rights, and bed-hold information.
Failure to provide appropriate pressure ulcer care occurred when a resident with diabetes, functional quadriplegia, immobility, and recent severe weight loss developed bilateral buttock wounds. Staff documented the areas inconsistently as stage 1 pressure wounds and excoriation, and there was no weekly wound assessment or documentation that the Wound Specialist or MD had seen the wounds. The resident was later observed on a low air loss mattress after reporting sores on his bottom.
Failure to Monitor and Address Severe Unplanned Weight Loss: A resident with DM2, functional quadriplegia, and GERD had severe unplanned weight loss while staff did not complete a COC, place him on weekly weights as expected, notify the MD, or document adequate RD reassessment and IDT review. The resident reported poor intake and inconsistent use of nutritional shakes, and the care plan was not updated to reflect the weight loss or related interventions.
Missed Blood Pressure Medication Administration: A resident with hypertensive heart disease and chronic kidney disease did not receive ordered metoprolol 25 mg daily. During med pass, an LPN administered multiple other medications, but later stated she missed the BP medication and thought it had been given. The ADON stated staff were expected to verify the resident, time, medication, route, and dose and to check the EMAR against the med card.
A resident with an overactive bladder did not receive their prescribed Oxybutynin Chloride due to its unavailability in the medication cart. Despite this, the MAR inaccurately recorded the medication as administered. The LN admitted to the error, and interviews with the DSD and DON highlighted that proper procedures for handling unavailable medications were not followed.
During a Covid-19 outbreak, staff at the facility failed to adhere to infection control precautions. Despite signage instructing mask use, LN 1, CNA 1, and CNA 2 were observed without masks. Interviews revealed awareness of the importance of mask-wearing, yet compliance was lacking. The DON confirmed the policy requiring mask use, highlighting a deficiency in infection control practices.
The facility failed to provide adequate training for kitchen staff in food sanitation and safety, resulting in improper testing of sanitizer solutions and incorrect food cooling procedures. Additionally, in-services on food safety were not conducted by qualified personnel, leading to potential risks of foodborne illnesses for residents.
The facility failed to develop an emergency menu that met the nutritional and therapeutic needs of its residents. During an inspection, it was found that the facility lacked a therapeutic menu for three days, and the emergency food supply was not calculated specifically for the health center residents. The emergency menu plan did not include provisions for residents on therapeutic diets, as required by facility policy.
The facility failed to maintain food safety and sanitation practices, with unclean ice machines, improper air gap systems, and grimy refrigerators. Cutting boards were worn, and food items were left uncovered, risking contamination. These deficiencies could lead to foodborne illness among residents.
The facility failed to follow its policy on the storage of outside food brought in by family members, risking foodborne illness. A CNA noted that food should be labeled and stored in the nursing station fridge, but an expired orange juice bottle was improperly labeled. The DSD admitted no specific training was provided on the policy, which requires discarding food after 72 hours. The DON stated food should be stored in a separate fridge to prevent contamination, and expired items should be discarded like medications.
A resident's room temperature was recorded at 88°F, exceeding the facility's policy range of 71°F to 81°F. The resident, who was cognitively intact and had a history of knee pain and falls, expressed discomfort due to the heat. The maintenance technician confirmed the high temperature, and the Director of Plant Operations acknowledged the importance of maintaining appropriate room temperatures for resident comfort.
A resident with Parkinson's disease received medications from an LPN who did not prepare them, leading to a potential safety issue. The LPN admitted the error, and the DON confirmed that the facility's policy requires the nurse who prepares medications to administer them to ensure safety.
The facility failed to implement physician's orders and notify the physician for three residents, leading to potential health risks. A resident refused physical therapy due to discomfort with the Rehabilitation Manager, and the physician was not informed. Another resident's daily weights were not recorded, and the physician was not notified of refusals. A third resident did not receive daily wound treatment as ordered, with no documentation of refusal.
The facility failed to ensure proper medication administration for four residents, including lack of parameters for PRN pain medications, incorrect timing of Parkinson's medication, and unavailability of a prescribed supplement. These issues were confirmed through interviews with staff and review of records, indicating potential unsafe medication practices.
A facility exceeded the acceptable medication error rate with two errors out of 30 opportunities. One resident did not receive Zinc Sulfate for wound healing due to unavailability in the medication cart, and another resident missed a Thera M Plus supplement during the morning medication pass. The DON confirmed that all medications should be administered per physician orders.
A medication cart's drawer containing residents' medications was left unlocked and unattended by nursing staff, as observed in the facility hallway. Licensed Nurse (LN) 34 confirmed the drawer was unlocked and unattended, acknowledging that all medication cart drawers should be securely locked when unattended. The Director of Nursing (DON) reiterated that nursing staff should always lock medication carts to prevent unauthorized access. The facility's policy requires medication carts to be closed and locked when out of sight.
The facility failed to provide palatable and flavorful meals, as residents reported dissatisfaction with the food being dry and lacking flavor. The Resident Council had previously raised concerns about tough meat and confusing menus. A test tray confirmed the BBQ chicken was dry, and the Dietary Supervisor was unaware of these issues. Additionally, residents on pureed diets did not receive nutritionally equivalent meals.
A resident at risk of weight loss due to poor intake was not provided meals in accordance with the finger food diet policy. Despite needing substantial assistance with eating, the resident was served a meal that did not comply with dietary recommendations, potentially impacting their nutritional status.
A staff member at the facility failed to perform hand hygiene before entering a resident's room, as observed during a survey. This action was against the facility's infection control policy, which requires all personnel to adhere to hand hygiene practices to prevent cross-contamination. Interviews with various staff, including the MRS, DSD, IP, and DON, confirmed the importance of this practice in protecting residents, staff, and visitors.
The facility failed to maintain kitchen equipment safely, with worn refrigerator gaskets and a damaged ice machine, risking contamination. The Dietary Supervisor and Food and Beverage Director acknowledged the issues, which violated the 2022 FDA Food Code and facility policy.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident who was identified as high risk for falls and had a recent history of a right femur fracture and generalized muscle weakness. The resident experienced a fall while attempting to reach his wheelchair to go to the bathroom, resulting in a skin tear on the back of the head and pain in the right hip. The incident occurred when the resident's call light was not activated, and he was found on the floor with his head slightly under the bed. The resident was assessed by the supervising nurse and subsequently transported to the hospital per physician's order, returning the same day. Despite the fall and the implementation of new interventions such as reiterating the use of the call light, lowering the bed, and using fall mats, there was no documentation in the resident's record reflecting these interventions upon return from the hospital. The Interim Director of Nursing confirmed that the care plan was not updated to reflect the fall or the new interventions. Facility policy requires staff and physicians to identify and document interventions to prevent subsequent falls and monitor the resident's response, but this was not completed in this case.
Failure to Follow Medication Administration Protocols for G-Tube Resident
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications to a resident with Myasthenia Gravis and a G-tube according to physician orders. The resident, who was tube-fed and not to receive anything by mouth, was found sitting in the hallway with her feeding tube disconnected. The nurse did not verify the resident's identity or the correct route of administration, crushed the medications, mixed them with applesauce, and gave them orally. This resulted in the resident choking and requiring suctioning and emergency services. Record review confirmed that the resident's medication orders specified administration via G-tube, with no recent changes to these orders. Facility policy required verification of resident identity and the five rights of medication administration, which were not followed in this incident. The nurse's last observed medication pass was several months prior, and the DON confirmed multiple failures in following medication administration protocols.
Improper Storage of Medications and Nutritional Supplements
Penalty
Summary
Medications and nutritional supplements were not properly stored in multiple areas of the facility, and one resident had medications unsecured at the bedside. Resident 78, admitted with diagnoses including hypotension and diabetes, was observed keeping three eye drops at the bedside in a paper cup on the overbed table: GenTeal, Optase for dry eyes, and gentamicin. The resident stated she self-administered one eye drop and asked a nurse to administer the thicker one. LN 1 stated medications should not be kept at bedside because the resident may double dose, and the IP and ADON stated a lock box should be provided if a resident self-administers medications. The facility’s self-administration policy stated self-administered medications must be stored in a safe and secure place not accessible by other residents. Medication storage areas also contained expired items. In station one medication room, LN 3 found an expired bottle of ibuprofen 200 mg with an expiration date of 7/20/25 and observed a bottle of Juven nutritional supplement on an open shelf with an expiration date of 8/1/25. In the main central supply room, LN 3 observed two bottles of povidone iodine with expiration dates of 8/2025, a box containing 24 bottles of Boost with an expiration date of 5/19/25 written on the box, and bisacodyl suppositories in a metal file drawer with an expiration date of 8/2025. LN 3 stated expired medications and nutritional supplements should not be kept because they may not achieve the desired effect, and the ADON stated stored medications should not be expired and that expired medications or nutritional supplements lose potency. The facility policy stated outdated, contaminated, discontinued, or deteriorated medications are to be immediately removed from stock and disposed of according to medication disposal procedures.
Food Served at Improper Temperature and Poor Palatability
Penalty
Summary
The facility failed to ensure food served was palatable, flavorful, and at a safe and appetizing temperature for six residents who complained that the food did not taste good and that warm food was served cold. During the initial tour on 8/5/25, six residents reported concerns about the food's taste and temperature. On 8/7/25 at 11:30 A.M., the trayline was observed serving Spanish fish soup, spaghetti, garlic bread, chicken pea stuffed peppers, rainbow chard, roasted beets, charred purple potatoes, sticky rice, and spinach. The Hot and Cold Food Temperature Logs for that meal showed the soup at 171 degrees Fahrenheit, the main entree at 161 degrees Fahrenheit, and the milk at 36.2 degrees Fahrenheit. At 12:25 P.M., a test tray sample was conducted with the Dietary Manager, who measured the soup at 157 degrees Fahrenheit and the spaghetti at 139.8 degrees Fahrenheit, showing a temperature drop from the trayline. The DM described the spaghetti as flat and noticeably lacking in salt, and stated the taste could be improved. Resident 85, who had a BIMS score of 13 and a regular diet with regular texture, stated the green substance on the tray was unrecognizable and said he did not eat it. Resident 86, who had a BIMS score of 15 and a regular diet with regular texture, stated the spaghetti did not have flavor and sent it back to the kitchen. Resident 89, who had a BIMS score of 12 and a no added salt, regular texture diet, stated the spinach was bad and the texture was not right. The DM stated that serving palatable and resident-preferred temperature foods was important to ensure residents enjoy the food and do not lose weight, and the facility did not provide a policy regarding food palatability and temperature.
Improper Food Labeling and Expired Items in Kitchen Refrigerators
Penalty
Summary
Food items in the kitchen reach-in refrigerators were not properly labeled, dated, or removed when expired. During an initial tour of the kitchen with the Dietary Aide, a large tub of opened cottage cheese was observed with no open date written on the container. A pack of sliced cheese was also found torn open with a smeared black marker date that was unreadable, and the Dietary Aide stated it should have been dated and securely wrapped. In addition, a large container of sliced peaches was observed with a Use By date of 8/1/25, and the Dietary Aide stated it should have been removed so it would not be served to residents by mistake. The Dietary Manager later stated that food items in the kitchen should be labeled and dated and that expired food items should have been removed. The facility's Trayline Labeling & Dating Guidelines dated 4/23/25 stated cottage cheese and sliced cheese were good for 6 days.
Failure to Assess Self-Administration of Eye Medications
Penalty
Summary
The facility failed to assess whether a resident could self-administer medications for one resident reviewed for self-administration of medications. The resident was admitted with diagnoses including hypotension and diabetes. During the initial tour, the resident was observed sitting at the edge of the bed with the right eye closed and stated that a nurse applied eye drops to the right eye while she applied eye drops to the left eye every hour. Review of the physician’s orders showed orders for autologous serum eye drops, GenTeal Tears Severe Day/Night ophthalmic gel, and other eye medications with directions including hourly supervised self-administration. During observation and interview, the resident stated she kept eye drops at her bedside and showed three eye drops in a cup, including GenTeal, Optase, and gentamicin. She stated she applied one eye drop herself but called a nurse for another because it was thicker and difficult to self-administer. Staff interviews confirmed there was no assessment for self-administration, and staff stated the resident should have had an assessment, physician’s order, care plan, and secure storage for the medications.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to provide a written and follow-up initiation of advance directives for one resident. The resident was admitted with diagnoses including COPD and was documented as responsible for herself at admission, with two durable powers of attorney for healthcare and financial matters. A later History and Physical stated the resident could not understand or decide because of dementia, and the POLST dated 6/22/24 had no information entered in Section D regarding an advance directive. Review of the resident’s medical record found no documented evidence of an advance directive and no evidence that the facility offered or followed up on advance directives. During an interview and record review, the Social Service Coordinator stated she was responsible for gathering advance directives during admission or care conferences and would document the offer if a resident did not have one. She also stated the resident did not have an advance directive in the medical record and should have. The facility policy stated staff would document the offer to assist and maintain copies of advance directive documents in the resident’s medical record.
Missing informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure that the authorized responsible party signed informed consent before psychotropic medications were administered to a resident with dementia and agitation. Resident 7 was admitted with diagnoses including dementia with agitation, and the MDS showed a BIMS score of 5, indicating severe cognitive impairment. The physician ordered Quetiapine Fumarate 100 mg at bedtime on 12/4/24 and Brexpiprazole 1 mg daily on 12/16/24, but the electronic medical record showed no documented signed informed consent for either medication. A review of the paper chart showed that the informed consent for Quetiapine Fumarate did not have the RP's signature, and no informed consent was present for Brexpiprazole. During interview, the ADON stated the RP should have signed informed consent before the psychotropic medication was administered. The RP stated she could not recall any discussion with staff or clinicians about the purpose, risks, or benefits of the medications before administration and said she signed the informed consent on 8/7/25. LN 3 later confirmed there was no informed consent for Brexpiprazole and that the Quetiapine Fumarate consent was signed on 8/7/25.
Failure to Provide Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to notify a resident and/or the resident's representative in writing of transfer/discharge notices and bed hold information for one resident who was sent to the emergency room twice after a fall. Resident 45 was re-admitted with diagnoses including a displaced fracture of the olecranon process and dislocation of the left shoulder joint. During observation, the resident was seen sitting in a wheelchair next to the bed with a dressing on the right arm near the elbow and stated he had fallen in the facility during the night and sustained a skin tear on the elbow. Record review showed staff found the resident on the floor face down on the right side, transferred him to the ER, and later sent him out again after x-ray results showed a dislocated left shoulder. Interviews with nursing staff and the Infection Preventionist indicated that notices of transfer/discharge and bed hold were not found in the record for both ER transfers. The facility policy stated that the resident and representative are to be notified in writing of the reason for transfer or discharge, the effective date, the location, appeal rights, and bed-hold policies.
Failure to Provide Weekly Wound Assessments and Accurate Pressure Injury Staging
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with type 2 diabetes, functional quadriplegia, GERD, and a history of falling who was admitted without pressure injuries and was assessed as at risk for pressure injury development on the Braden Scale. The resident was later observed lying in bed on a low air loss mattress and stated the facility provided the bed after he had sores on his bottom. The record showed bilateral buttock wounds documented as open areas, with one progress note describing two open wounds on the bilateral buttocks measuring 1 cm by 1 cm with no drainage or odor. The facility did not conduct weekly wound assessments for the resident's pressure injuries, and staff could not find documentation that the Wound Specialist or physician had seen the wounds. Nursing documentation also did not accurately identify the wound stage, with one note describing the areas as stage 1 pressure wounds and another charting them as excoriation, while the licensed nurse stated the open wounds should have been documented as stage 2 pressure injuries. The ADON acknowledged the resident was at high risk for skin breakdown due to immobility and recent severe weight loss and stated the wounds should have been assessed during weekly wound visits to clarify staging and promote optimal healing.
Failure to Monitor and Address Severe Unplanned Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive system to monitor and respond to a resident’s nutritional decline when Resident 3 experienced severe, unplanned weight loss. Resident 3 was admitted with diagnoses including type 2 diabetes, functional quadriplegia, GERD, and a history of falling. His MDS indicated intact cognition. During observation, he was in bed eating breakfast and stated that lunch and dinner were hit or miss, that he had not cared for the food over the last couple of weeks, and that he had recently lost weight. He also reported receiving a diabetic nutritional shake with meals but said he did not always finish it. His wife stated that he was losing weight and often chose alternative menu items. The weight record showed a decline from 165.2 lbs. to 140.8 lbs., including a 17.1 lb., 10.35% severe weight loss over 90 days and a total loss of 24.4 lbs., or 14.77%, from 4/5/25 to 8/6/25. The RD completed a nutrition evaluation on 4/7/25 noting poor intake, moderate nutrition risk, and a goal to remain weight stable, with monitoring of intake, weight, and labs. A later nutrition evaluation on 7/7/25 documented that the resident was at potential risk for weight loss, dehydration, and malnutrition related to variable oral intake and recent weight loss trend, but it also stated there were no new interventions or recommendations. The record review and interviews showed no documentation of interventions for the weight loss. Facility staff stated that significant weight loss should be treated as a change of condition, but no change of condition was completed for Resident 3’s weight loss and the physician was not notified. The RN/RD-related interviews indicated the resident was not placed on weekly weights as expected, the RD did not reassess the weight loss to determine interventions, and the IDT did not address the severe unplanned weight loss. The care plan was not updated to reflect the weight loss, and the nutritional shake was not listed in physician orders. Staff also stated there was no documentation of how much of the nutritional shake the resident consumed, despite concerns that he was not finishing it.
Missed Blood Pressure Medication Administration
Penalty
Summary
Resident 25 was re-admitted to the facility with diagnoses including hypertensive heart disease and chronic kidney disease. During a medication observation, Licensed Nurse 2 administered nine medications to the resident, including bumetanide, flecainide acetate, famotidine, vitamin C, vitamin D3, a multivitamin, fluticasone nasal spray, chewable aspirin, and amlodipine. A joint observation, interview, and record review showed that Resident 25's physician's orders also included metoprolol 25 mg daily, a blood pressure medication, but it was not given. Licensed Nurse 2 reviewed the physician's orders and the medication card for metoprolol and stated she missed giving the medication and thought she had administered it. The Assistant Director of Nursing stated staff were expected to verify the resident, time, correct medication, route, and dose, and to check the EMAR against the medication card and repeat the process to ensure all medications were administered according to physician's orders.
Medication Administration Error Due to Unavailability
Penalty
Summary
The facility failed to ensure proper medication administration for a resident with an overactive bladder. During a medication pass, it was observed that the resident's prescribed medication, Oxybutynin Chloride, was not available in the medication cart. Despite this, the Medication Administration Record (MAR) indicated that the medication had been administered. Upon review, the Licensed Nurse (LN) admitted that the medication was not given because it was not available and acknowledged that it was incorrectly documented as administered. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the facility's procedures were not followed. The DSD stated that if a medication is not available, a note should be written, and the pharmacy should be followed up with. The DON emphasized the importance of notifying the physician and using an urgent pharmacy form to obtain medications promptly. The facility's policy requires documentation if a medication is withheld or given at a different time, which was not adhered to in this case.
Infection Control Deficiency During Covid-19 Outbreak
Penalty
Summary
The facility failed to ensure staff adhered to infection control precautions during a Covid-19 outbreak, as observed during an unannounced visit. Despite a sign on the entrance door indicating the presence of Covid-19 and instructing visitors to wear masks, staff members were observed not complying with these precautions. At 5 A.M., LN 1 was seen at nursing station 1 without a surgical mask, despite acknowledging the presence of a Covid-19 positive resident in the facility. Similarly, CNA 1 and CNA 2 were observed entering the hallway from resident rooms without masks, with CNA 1 admitting to having been in a resident room without a mask. Interviews with the staff further highlighted the deficiency in infection control practices. CNA 2 acknowledged the importance of wearing masks to prevent asymptomatic spread of Covid-19, while CNA 1 admitted to not wearing a mask when required. The Infection Preventionist confirmed that one resident was still on precautions for Covid-19. The Director of Nursing stated that it was the facility's policy and expectation for all staff to wear surgical masks during the outbreak, indicating that LN 1, CNA 1, and CNA 2 were not in compliance with the facility's infection control policy.
Deficiencies in Kitchen Staff Training and Food Safety Practices
Penalty
Summary
The facility failed to ensure that kitchen staff received appropriate training in food sanitation and safety, leading to several deficiencies. Three dietary aides demonstrated improper methods for testing sanitizer solutions used for sanitizing equipment and prep surfaces, which could lead to cross-contamination. One aide incorrectly tested the chlorine solution in a dish machine, while another used an ammonia test strip incorrectly and did not log the results. A third aide recognized incorrect sanitizer levels but did not take immediate corrective action. The facility's sanitation logs were incomplete, and the staff did not adhere to the facility's policies and procedures for sanitation. Additionally, two cooks were unable to correctly verbalize the two-step cool down process for foods, which is crucial for preventing bacterial growth. One cook incorrectly described the process and was unaware of the time required to cool foods using a blast chiller. The facility's policy and the FDA Food Code require specific cooling procedures to ensure food safety, which the cooks failed to follow. The facility also did not conduct staff in-services on food safety and sanitation by a qualified kitchen staff member. The Sous Chef, who conducted some in-services, did not have the necessary Certified Dietary Manager credentials. There was no documentation of specific in-services on food safety and sanitation topics conducted by qualified personnel between January 2021 and January 2024. This lack of proper training and documentation could potentially expose residents to foodborne illnesses.
Failure to Develop Adequate Emergency Menu
Penalty
Summary
The facility failed to ensure an emergency menu with appropriate food and water supplies was developed to meet the nutritional and therapeutic needs of the residents. During an observation and interview, it was revealed that the facility did not have a therapeutic menu for three days to feed 50 residents. The Acting Administrator, Safety and Transportation Director, Dietary Supervisor, Food and Beverage Director, Executive Chef, and Sous Chef acknowledged that the facility's 3-day food supply was combined with emergency foods for the entire senior residential care community. The meal count and water supply needed to be calculated specifically for the health center facility beds, and there was a lack of a sufficient menu to meet the medical and therapeutic needs of the residents. Further review of facility documents and interviews with the Registered Dietitian and Dietary Supervisor confirmed that the emergency menu plan did not include residents on therapeutic diets or provide clear instructions for feeding residents on therapeutic and textured diets. The facility's policy and procedure documents indicated that therapeutic diets should be planned and served according to the state-approved Diet Manual and that a preplanned emergency menu should be available. However, the facility's current emergency menu did not meet these requirements, potentially compromising the nutritional and health status of the residents.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in dietary services, as observed in several areas. Two ice machines were not cleaned and maintained according to the manufacturer's instructions, with visible mold and debris inside the machines and expired water filters. The facility contractor demonstrated the cleaning process but acknowledged that certain parts, such as the baffle and water filters, were not cleaned or replaced. The facility's policy required regular cleaning, but the maintenance logs indicated lapses in adherence to these schedules. Additionally, the facility did not ensure proper air gap systems for three ice machines and one dish machine, which are necessary to prevent backflow of contaminated fluids. Observations revealed that pipes were improperly extended into floor sink drains, and the Director of Plant Operations confirmed the need for an air gap space. This oversight contravenes the Federal FDA Food Code, which specifies the required air gap dimensions to prevent contamination. The facility also failed to maintain cleanliness in food storage areas. Two reach-in refrigerators had grimy debris on the door gaskets, and the facility's cleaning schedules were not provided upon request. Furthermore, cutting boards were found to be heavily worn and discolored, and multiple food items were left uncovered during transport, increasing the risk of cross-contamination. These deficiencies had the potential to cause widespread foodborne illness among the residents receiving food from the kitchen.
Failure to Implement Policy on Outside Food Storage
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought in by family members for residents, which could potentially lead to foodborne illnesses. During an observation, a Certified Nursing Assistant (CNA) revealed that outside food is stored in the nursing station nourishment room refrigerator and should be labeled with the resident's name and date. However, a 32-ounce bottle of unopened orange juice was found labeled only with a room number and was expired. The Director of Staff Development (DSD) acknowledged that outside food should be discarded after 72 hours, not one week, and admitted that no specific in-service training had been provided to the nursing staff regarding this policy. The Director of Nursing (DON) stated that outside foods should not be stored in the nursing station fridge but in a separate resident nourishment fridge in the dining room to prevent cross-contamination. The facility's policy from 2013 indicated that refrigerated foods must be labeled with the resident's name, room number, and date, and discarded within 72 hours. Another policy from 2015 stated that food items should not be stored in medication refrigerators. The DON emphasized that expired food should be treated like medications and discarded to prevent foodborne illnesses, and that nursing staff should be aware of the 72-hour discard rule.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to ensure a comfortable environment for one of its residents, identified as Resident 216, when the room temperature was recorded at 88 degrees Fahrenheit. Resident 216, who was cognitively intact and admitted with diagnoses including right knee pain and a history of falls, was observed fanning himself with a table napkin and expressed discomfort due to the heat. This observation was made during an interview on June 4, 2024, at 9:43 A.M. Further investigation revealed that the facility's maintenance technician confirmed the room temperature using a thermal gun, which registered 88 degrees Fahrenheit, while Resident 216's preferred room temperature was 79 degrees Fahrenheit. The Director of Plant Operations later stated that the room temperatures for all residents should be maintained between 71 and 81 degrees Fahrenheit to ensure comfort. The facility's policy on maintaining a homelike environment, revised in February 2021, also specified that room temperatures should be kept within this range.
Medication Administration Error Due to Staff Miscommunication
Penalty
Summary
The facility failed to ensure the safe administration of medications for one resident, identified as Resident 500, due to improper medication handling by the nursing staff. Resident 500, who was admitted with diagnoses including Parkinson's disease, muscle weakness, and restless legs, was involved in an incident where medications were administered by a nurse who did not prepare them. During an observation, Resident 500 questioned the nurse, LN 31, about the medications in the cup, to which LN 31 admitted she did not prepare them and would need to consult with LN 2, who had prepared the medications. Interviews with the involved staff revealed that LN 31 acknowledged she should not have administered the medications since she did not prepare them, and LN 2 admitted she should have administered the medications herself to ensure safety. The Director of Nursing confirmed that the facility's policy requires the nurse who prepares the medications to administer them to prevent confusion and ensure a safe environment. The facility's policy on administering medications emphasizes verifying the right resident, medication, dosage, time, and method before administration.
Failure to Implement Physician's Orders and Notify Physician
Penalty
Summary
The facility failed to implement physician's orders and notify the physician for three residents, leading to potential health risks. Resident 61, who was admitted with a fractured left femur, had a physician's order for physical therapy five times a week. However, the resident refused treatment due to discomfort with the Rehabilitation Manager, and the physician was not informed of these refusals, contrary to the facility's policy. Resident 45, diagnosed with esophageal obstruction and severe protein-calorie malnutrition, had a physician's order for daily weights. The resident's weights were not recorded on multiple occasions, and the resident reportedly refused to be weighed. Despite this, the physician was not notified of the refusals, which was necessary to address the resident's reasons for refusal and discuss potential consequences. Resident 55, with diabetes mellitus and an acute embolism, had a physician's order for daily wound treatment on the left lower leg. The treatment was not performed on two consecutive days, and there was no documentation of refusal. The lack of treatment and documentation was against the physician's order and the facility's policy, which required daily wound care to monitor and prevent deterioration.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper procedures for medication administration for four residents, leading to potential unsafe medication practices. Resident 314 and Resident 315 were prescribed PRN medications for pain without clear parameters for administration, such as a pain scale or numeric pain level. Interviews with the Director of Nursing and the Director of Staff Development confirmed that PRN medications should have specific indications for use, which were not provided in these cases. Resident 316 did not receive their Carbidopa-Levodopa medication in accordance with the physician's order, which specified administration one hour before meals. The medication was instead given at times that coincided with or followed meal times, contrary to the prescribed schedule. This discrepancy was confirmed through interviews with the resident, the Minimum Data Set Coordinator, and the facility's Pharmacy Consultant, all of whom acknowledged the importance of adhering to the prescribed timing to ensure the effectiveness of the treatment. Resident 61 did not receive their prescribed Zinc Sulfate due to its unavailability in the medication cart. The Licensed Nurse responsible for administering the medication confirmed its absence, and the Pharmacy Consultant emphasized that all prescribed medications should be readily available for administration. The Director of Nursing also stated that medications should be accessible at all times to meet residents' needs, highlighting a failure in the facility's medication management system.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 6.67%, exceeding the acceptable threshold of 5%. This was due to two medication errors occurring out of 30 opportunities during medication administration. The first error involved a resident who was admitted with a diagnosis of a fractured left femur. The resident had a physician's order for Zinc Sulfate 220 mg daily for wound healing, but the medication was not administered by the licensed nurse during the observed medication pass. The nurse stated that the Zinc Sulfate was not available in the medication cart, which led to the failure to administer the prescribed medication. The second error involved another resident who had a physician's order for Thera M Plus, a multivitamin supplement, to be taken orally once daily. During the medication pass observation, the licensed nurse was unable to administer the supplement as prescribed. The nurse acknowledged that the resident should have received the supplement during the morning medication pass. The Director of Nursing confirmed that all prescribed medications should be administered by the nursing staff according to physician orders. The facility's policy on administering medications, revised in April 2019, states that medications are to be administered safely, timely, and as prescribed.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that medications were securely locked inside a medication cart, as observed on June 4, 2024, at 9:27 A.M. A medication cart's drawer containing residents' medications was left unlocked and unattended by a nursing staff member in the facility hallway. During a joint observation and interview on June 6, 2024, at 9:29 A.M., Licensed Nurse (LN) 34 confirmed that the medication cart's drawer was unlocked and unattended. LN 34 acknowledged that all medication cart drawers should be securely locked when unattended to prevent unauthorized access to medications. An interview with the Director of Nursing (DON) on June 7, 2024, further confirmed that nursing staff should always lock medication carts to prevent unauthorized access. A review of the facility's policy titled 'Administering Medications,' revised in April 2019, indicated that the medication cart should be kept closed and locked when out of sight of the medication nurse or aide.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, flavorful, and maintained its nutritional value, as observed during a dining session. Several residents expressed dissatisfaction with the food, describing it as unappetizing, dry, and lacking flavor. The Resident Council meeting minutes from February to April 2024 highlighted ongoing dietary concerns, including tough meat and confusing menus. During a test tray observation, the BBQ chicken was found to be dry and lacking seasoning, which was acknowledged by the Dietary Supervisor and the Food and Beverage Director. The Registered Dietitian confirmed mixed reviews about the meals, noting that they were often described as boring and sometimes tough. Additionally, residents on pureed diets did not receive nutritionally equivalent meals compared to those on regular diets. The Dietary Supervisor was unaware of the resident council's concerns, indicating a lack of communication and follow-up on dietary issues. The facility's policy on addressing food complaints was not effectively implemented, contributing to the deficiency.
Failure to Follow Finger Food Diet for Resident
Penalty
Summary
The facility failed to adhere to dietary recommendations for a resident on a finger food diet, which was crucial for addressing the resident's risk of weight loss. The resident, who was admitted with paroxysmal atrial fibrillation and had moderate cognitive impairment, required substantial assistance with eating. A nutritional evaluation indicated the resident was at high nutritional risk due to poor intake and a recent weight loss of 3.8 pounds over six days. Despite these concerns, during a dining observation, the resident was served a meal that did not comply with the finger food diet policy, as the sandwich was not cut into fourths as required. Interviews with the facility's Registered Dietitian and Dietary Supervisor confirmed that the resident preferred finger foods and was on a regular texture diet. They acknowledged the oversight in meal preparation, which did not align with the facility's Finger Food Diet policy. This failure to provide food in the correct form had the potential to negatively impact the resident's food intake and exacerbate weight loss, as supported by the Academy of Nutrition & Dietetics' findings on unintended weight loss and increased mortality in older adults.
Failure to Perform Hand Hygiene Before Entering Resident's Room
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by a staff member, specifically in the case of a Medical Records Staff (MRS) who did not perform hand hygiene (HH) before entering a resident's room. This incident was observed on June 4, 2024, when the MRS entered the room of a resident to respond to a call light without washing hands or using hand sanitizer. This action was contrary to the facility's policy, which mandates that all personnel adhere to hand hygiene practices to prevent the spread of infections. Interviews conducted with the MRS, the Director of Staff Development (DSD), the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that the MRS should have performed hand hygiene before entering the resident's room. Each of these staff members acknowledged the importance of hand hygiene in preventing cross-contamination and protecting residents, staff, and visitors from potential infections. The facility's policy, revised in October 2023, clearly states the expectation for all personnel to follow hand hygiene protocols.
Deficiency in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as observed during a survey. Two reach-in refrigerators had door gaskets that were worn, torn, and detaching, which could compromise the seal and lead to contamination. The Dietary Supervisor and the Food and Beverage Director acknowledged the issue and stated that the gaskets needed replacement. According to the 2022 Federal FDA Food Code, non-food contact surfaces must be kept free of debris to prevent microorganism growth, which could be transferred to food. Additionally, an ice machine in the main kitchen had a broken plastic piece on the bin door, leaving a large hole, and the rubber seals were torn and covered with calcium-like deposits. The inside of the ice machine showed discoloration, indicating potential contamination. The facility's ice machine maintenance log showed scheduled maintenance dates, but the issues persisted. The Director of Plant Operations expected all equipment to be operational and on a preventive maintenance schedule. The facility's policy required equipment to be maintained according to manufacturer's instructions, which was not adhered to in this case.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 589 citations issued within 25 miles in the last 12 months — including the 3 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.
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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 San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Rancho Bernardo Care Center | 3.3 mi | ★★★★★ | 1 | 0 |
| Ocean View Post Acute | 3.4 mi | ★★★★★ | 0 | 0 |
| The Villas At Poway | 3.6 mi | ★★★★★ | 0 | 0 |
| Poway Healthcare Center | 3.7 mi | ★★★★★ | 3 | 0 |
| Boulder Creek Post Acute | 4 mi | ★★★★★ | 0 | 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 June 2026) and official state health department websites.