Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citrus Grove Post Acute during CMS and state inspections, most recent first.
A resident with dementia and muscle weakness experienced an unwitnessed fall in the bathroom and was later noted by family to have a black eye, but the physician and responsible party were not notified immediately, and physician notification was delayed by two days. Documentation showed the event as a change in condition, yet required notifications and a Change of Condition (COC) process were not initiated. An LVN reported being unaware of any change from the prior shift, a CNA stated she did not know the incident needed to be entered as a New Alert, and another LVN admitted forgetting to report the incident to the RN, physician, and family. The DON stated that such a fall is considered a change in condition requiring immediate assessment, care plan updates, and notification, consistent with facility policy.
A resident with dementia and muscle weakness experienced an unwitnessed fall and was later found sitting on the bathroom floor without apparent injury and with VS WNL. Although the event was documented as a change in condition in a late entry, staff did not perform or document ongoing assessments for delayed injury over the next two days, and the care plan was not reviewed or revised to address the fall or implement fall-prevention interventions. An LVN reported he was not informed of a change in condition and that the change-in-condition documentation and monitoring began late, while the DON confirmed that required assessment, monitoring, and care-plan revision did not occur because the change-in-condition process was not initiated promptly.
A resident with muscle weakness and unsteadiness on feet, who required minimal to moderate assistance with ADLs and transfers, was discharged home with IHSS and expected family support without the IDT confirming caregiver availability, capacity, or hours. The SSD relied on the resident’s report that IHSS and the daughter’s help were in place and did not contact the daughter or include her in discharge planning. PT and OT documented the need for caregiver assistance and support at home, but no caregiver training was provided, and there was no IDT discussion of required caregiver hours or level of assistance. The resident returned to the facility the next day after the daughter reported that IHSS hours were less than anticipated and insufficient to meet the resident’s care needs.
A resident with significant medical and mobility needs was discharged to an unlicensed room and board without proper assessment or verification that the setting could meet care requirements. The resident, dependent on a wheelchair and needing assistance with ADLs, was confined to the kitchen area and unable to access essential facilities, resulting in a hospital transfer two days later. Facility staff did not adequately communicate or assess the discharge location or the resident's needs.
A resident who was always incontinent and required substantial assistance remained in a soiled brief for about an hour after notifying staff, despite facility expectations for timely incontinence care every two hours and as needed. The CNA acknowledged the resident's need but delayed providing care, and staff interviews confirmed this did not meet facility policy for prompt response and dignity.
A resident with chronic gout missed a scheduled dose of prescribed oxycodone for pain management due to the facility's failure to reorder the medication in a timely manner. Nursing staff did not request a refill before the supply was depleted, and no oxycodone was available in the emergency kit, resulting in the missed dose as documented in the MAR and confirmed by staff interviews.
Dietary staff failed to test the quaternary sanitizing solution according to the manufacturer’s instructions. An observation showed a DA dipped the test strip and waited 15 seconds before comparing it to the color chart, while the product instructions required a 10-second immersion and immediate comparison. The RD confirmed the strips should be used per the manufacturer’s directions.
A facility failed to maintain resident dignity and privacy when one resident waited for lunch while her roommate was already eating, a resident's Foley catheter drainage bag was left uncovered and visible, and an LVN entered another resident's room without knocking. CNAs, the LVN, and the DON all acknowledged that meals for roommates should be served at the same time, Foley bags should be covered, and staff should knock before entering resident rooms.
Failure to provide written bed-hold notice at transfer. A resident with depression was sent to a hospital for further evaluation while alert and verbally responsive, but the bed-hold notification form was left blank and there was no documented evidence that the resident or RP received written notice of bed-hold rights at the time of transfer. An LVN stated she did not notify the resident about the bed-hold policy, and the DON stated nurses are expected to complete the form at admission and again at transfer.
A resident was served the wrong breakfast tray after staff failed to verify the full name on the meal ticket against the resident’s identity, and the tray was intended for another resident with different diet orders. In a separate issue, an LPN/LVN failed to change another resident’s oxygen nasal cannula weekly as required; the tubing was observed without a change date and staff confirmed it had not been changed in accordance with facility practice.
Failure to maintain resident fingernail hygiene: A resident with dementia and diabetes was observed with long, yellowish fingernails. A CNA, LVN, DSD, and DON stated CNAs and LVNs were responsible for daily hygiene care, including checking, cleaning, and trimming fingernails, but the resident’s nails were not maintained and there was no documentation explaining why they remained long.
A resident with anxiety disorder and PBA was ordered Nuedexta twice daily, but MARs and nursing notes showed multiple missed doses and conflicting documentation that the medication was administered before it was actually received from the pharmacy. The DON and an LVN confirmed the medication was not available for several days, while the MAR still reflected doses as given, and the facility could not identify the medication on hand before the delivery was verified.
The facility failed to ensure the physician reviewed and addressed a CP’s monthly MRR recommendation for a resident with dementia and bipolar disorder. The CP recommended considering a GDR of buspirone 20 mg three times daily with the goal of discontinuation, but the record showed no documentation that the physician reviewed, accepted, or rejected the recommendation. The DON stated there was no documented evidence the recommendation was communicated to the physician when received.
Failure to Use Required PPE for EBP: An LVN provided bedside care to a resident on EBP without wearing the required gown while administering oral meds, eye drops, and a breathing treatment. The resident had a stage 3 sacral pressure ulcer, and the record showed EBP orders and a care plan calling for gloves and gowns during high-contact care. The IP and DON stated staff were expected to follow the posted precaution signage and wear the required PPE.
A room was found to have five residents assigned to it, exceeding the limit of four residents for the space. Surveyors observed the over-occupancy during the initial tour and reviewed records showing the room measured 440.94 sq ft, providing 88.18 sq ft per resident. Interviewable residents stated they were comfortable in the room and did not want to change rooms.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
A resident with dysphagia and a physician-ordered fortified puree diet was given cotton candy by a Business Office Manager, despite care plan and dietary orders requiring a puree texture. The incident was observed by an LVN, and both the RD and ADON confirmed that the resident should not have received the cotton candy, as it was not compatible with the prescribed diet and placed the resident at risk.
A resident with left-sided weakness from a stroke and contracture was found to have their call light placed on their weaker side, making it inaccessible. Staff interviews confirmed the call light should have been on the resident's strong side, and both the care plan and facility policy required the call light to be within reach.
A linen shortage in the facility led to delays in care for two residents, as they had to wait for linens, washcloths, and towels to become available before receiving necessary care. Staff, including LVNs and CNAs, reported ongoing issues with linen availability, which had been affecting care for one to two months. The Director of Nursing confirmed the shortage and acknowledged that the facility lacked a specific policy on linen quantity, despite expectations to maintain sufficient supplies.
A facility failed to complete post-dialysis assessments for a resident with end-stage renal disease and diabetes on two occasions. The absence of these assessments was confirmed through a review of the resident's Dialysis Communication Record. Staff interviews revealed that the missing assessments could lead to unawareness of critical health changes. The facility's policy emphasized the importance of documentation, which was not followed in this case.
A resident with end-stage renal disease and other conditions was not provided hand hygiene before a meal, contrary to the facility's infection control policy. The CNA allowed the resident to touch and eat food without cleaning their hands, despite visible residue under the fingernails. Both the CNA and ADON acknowledged the oversight, which goes against the facility's procedures to prevent infection spread.
The facility did not ensure that staffing information was accessible to residents and visitors. During an unannounced visit, surveyors found the staffing information hidden and outdated. The Director of Staff Development confirmed that the information should be posted visibly and updated daily, as per facility policy.
A resident was repeatedly served pork despite clear instructions on their meal ticket indicating 'NO PORK' due to cultural preferences. The facility's policy requires adherence to residents' dietary preferences, but this was not followed, potentially affecting the resident's nutritional intake.
A resident was found self-administering A&D ointment without a prior assessment to determine the safety and appropriateness of this practice. The resident's medical records lacked documentation of such an assessment, and an LVN acknowledged that it should have been conducted. The facility's policy mandates an interdisciplinary team assessment before allowing self-administration of medications.
Expired medications, including Gabapentin, Tramadol, and Dicyclomine, were found in a medication cart during a survey. An LVN acknowledged the medications were expired and should have been removed and disposed of properly. The ADON confirmed that expired medications should be removed to ensure resident safety, as per facility policy.
The facility failed to ensure proper training for dietary staff, leading to potential food safety risks. The Dietary Aide incorrectly tested chlorine sanitizing solution concentration, and the Cook was unable to verbalize the correct food cool down process. These deficiencies could expose residents to foodborne illnesses.
A facility failed to follow infection control protocols during wound care, maintain cleanliness in linen closets, and ensure PPE usage in a precaution room. An LVN did not change gloves or perform hand hygiene during wound care for a resident with a Stage 4 pressure ulcer. Two linen closets were found unclean, and a nurse entered a precaution room without PPE, despite a resident having CRE bacteria.
Two residents experienced a lack of dignity in their care at the facility. A CNA failed to assist a resident with Alzheimer's to the bathroom, instructing her to use her incontinence pad instead. Another resident was not served lunch with others at the same table, leading to feelings of exclusion. Both incidents were acknowledged by staff as dignity issues, contrary to the facility's policy on resident respect and well-being.
The facility did not report an alleged abuse incident between two residents to the CDPH within the required two-hour timeframe. A resident with anxiety reported feeling threatened after another resident allegedly bumped into her wheelchair intentionally. Despite the incident being reported internally, it was not communicated to the state agency as mandated by the facility's policy.
A facility failed to update a resident's care plan after readmission with a new diagnosis of CRE bacteremia, leading to a nurse being unaware of necessary contact precautions. The resident's plan of care was not revised to include the new diagnosis and required isolation measures, as confirmed by the Infection Preventionist and Director of Nursing. This oversight resulted in the nurse providing care without appropriate PPE, despite a contact precaution sign being present.
Two residents were found using medications without physician orders, contrary to facility policy. One resident self-administered A&D ointment for skin irritations, while another used eye drops brought by a friend for dry eyes. Both cases lacked the necessary physician orders, as confirmed by facility staff.
A resident identified as a fall risk did not have a floor mat in place as required by their care plan. Despite being admitted with conditions such as altered mental status and unsteadiness, the facility failed to implement this intervention, as confirmed by staff interviews. The facility's policy emphasized the need for targeted interventions, which was not followed in this instance.
Two residents in the facility were found to have deficiencies in respiratory care. One resident's oxygen tubing was not date-labeled, and another resident was using oxygen without a physician's order, contrary to facility policy. Staff confirmed these oversights, which could lead to infection control issues and improper care.
A facility failed to ensure that food brought by visitors was not expired and safe for consumption, risking foodborne illness. An observation revealed that a resident's food items, including hot dogs and sandwiches, were stored without proper date labeling and had past discard dates. The ADON confirmed these items should have been discarded as per facility policy.
A resident admitted with sepsis required contact isolation due to CRE in the urine, but the physician order was not transcribed into the EMR. The IP received the order but failed to transcribe it, which was confirmed by the DON. Facility policy requires timely transcription of physician orders.
A resident's call light was found to be non-functional during an observation and interview. The resident reported the issue, and a CNA confirmed the malfunction. The facility's policy mandates that call lights must be operational at all times.
A facility was found to have a room accommodating five residents, exceeding the regulatory limit of four. The room provided 88.18 sq ft per resident, which is insufficient for five individuals. Despite this, no adverse effects were observed, and residents reported being comfortable.
A facility failed to notify a resident's representative about the addition of Lorazepam to the resident's medication regimen. The resident, under hospice care and severely cognitively impaired, had appointed a representative for medical decisions. Despite the facility's policy requiring notification, there was no documentation that the representative was informed, leading to concerns about overmedication.
A resident with severe cognitive impairment and kidney cancer was unable to change hospice providers due to the facility's failure to follow up on a Letter of Agreement (LOA) for hospice services. The resident's representative had requested the change, and the new hospice reached out for approval, but the facility did not respond for over a month. The Administrator admitted to not following up on the LOA due to being out of the country and not delegating the task.
Failure to Immediately Notify Physician and Family After Resident Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and responsible party after a significant change in condition related to an unwitnessed fall. The resident, who had diagnoses including muscle weakness and dementia, was found on the bathroom floor on the evening of January 23, 2026, sitting up and holding onto the toilet, with skin intact, no complaints of pain, vital signs within normal limits, and alert and oriented at baseline. A late-entry progress note documented this event as a change in condition, with the resident stating she slipped and did not hit her head. However, there was no documented evidence that the responsible party was notified immediately after the incident, and the physician was not notified until two days later, on January 25, 2026. A family member later observed that the resident had a black eye and reported not having received any call from the facility about an incident. Staff interviews further clarified the inactions that led to the deficiency. The LVN assigned to the resident on the day the responsible party called stated he did not observe a black eye and was unaware of any change in condition from the previous shift. The CNA who worked the evening when the resident was found on the bathroom floor stated she did not know the incident needed to be documented under a New Alert so it would be visible to other staff. Another LVN acknowledged she forgot to report the incident to the RN, the physician, the family, and did not initiate a Change of Condition (COC), despite stating that reporting and initiating a COC was the expected practice. The DON confirmed that the fall was a change in condition and that staff were expected to assess, monitor, initiate and update the care plan, and immediately notify the physician and responsible party, consistent with the facility’s policy on change in condition notification.
Failure to Timely Assess and Revise Care Plan After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely and ongoing assessment, monitoring, and care-plan revision following a resident’s change in condition after an unwitnessed fall. The resident, admitted with diagnoses including muscle weakness and dementia, was found on January 23, 2026, in a sitting position on the bathroom floor holding onto the toilet, with no apparent injury, intact skin, no complaints of pain, vital signs within normal limits, and alert and oriented at baseline. A late-entry progress note documented this event as a change in condition, with the resident verbally stating that she slipped and did not hit her head. However, there was no documented evidence that staff conducted ongoing assessments for delayed injuries or monitoring on January 23 and January 24 following the unwitnessed fall. Record review further showed there was no documentation that the resident’s care plan was reviewed or revised to address the fall or to implement interventions to prevent further incidents. An LVN reported that he was assigned to the resident the day the responsible party called about the resident having a black eye and not being informed, and he stated he had not received any report of a change in condition due to a fall. He also stated that, per facility practice, once a resident has a change in condition, the licensed nurse should assess the resident for the next 72 hours, but the change-in-condition documentation was not created until two days after the fall, and ongoing monitoring and assessment did not begin until the day after the fall. The DON confirmed that the incident was a change in condition and that, because the change-in-condition process was not initiated, there was no ongoing assessment, monitoring, or care-plan revision for the resident.
Failure to Coordinate Caregiver Support for Safe Discharge Home
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge for a resident who required assistance with activities of daily living and caregiver support at home. The resident had diagnoses including muscle weakness and unsteadiness on feet and, per the discharge plan dated January 12, 2026, required assistance with household tasks such as meal preparation, bill paying, simple cleaning, transfers from bed to chair, and walking. Occupational therapy documented that the resident needed minimal help with feeding, personal hygiene, bathing, dressing, and toilet use, and moderate help with transfers. Physical therapy documented that the resident was to be discharged home with support and assistance from others, including community assistance and caregiver availability in the morning and afternoon. Nursing notes indicated the resident was discharged home on January 14, 2026, with IHSS services. Interviews and record review showed that the Interdisciplinary Team (IDT) did not coordinate or verify the availability, capacity, or adequacy of caregiver support and services prior to discharge. The SSD relied solely on the resident’s report that IHSS services and the daughter’s assistance were in place and did not contact the daughter to confirm caregiver availability or ability to provide care. The resident’s daughter was not included in the discharge planning discussion, and there was no IDT discussion regarding caregiver hours, caregiver training, or the level of assistance required at home. The DOR stated the resident required caregiver support during daytime and nighttime hours and that caregiver training would have been required if a family member were to provide care, but no such training was provided. The DON acknowledged that nursing and rehabilitation did not coordinate discharge needs with Social Services, including caregiver training and required hours, and the resident returned to the facility the day after discharge when the daughter reported that approved IHSS hours were less than anticipated and insufficient to meet the resident’s care needs.
Failure to Ensure Safe and Appropriate Discharge Placement
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident with multiple complex medical conditions, including chronic gout, pneumonia, major depressive disorder, and acute kidney failure. The resident required assistance with activities of daily living (ADLs) such as transfers, toileting, bathing, and bed mobility, and was dependent on a wheelchair. Despite these needs, the facility discharged the resident to an unlicensed room and board setting without verifying that the environment could meet the resident's care requirements. The discharge documentation indicated the resident needed assistance with most ADLs, yet this information was not communicated to the receiving setting. Interviews revealed that the room and board manager did not assess the resident in person prior to admission and relied on a phone interview, during which the resident claimed to be independent. The facility's social services department did not follow up with the room and board manager after learning of the placement, and the third-party placement coordinator provided contact information but was unaware of the resident's care needs. The discharge packet sent to the third-party representative did not include documentation of the resident's functional or ADL status. As a result of these failures, the resident was confined to the kitchen area at the room and board facility, unable to access the restroom or maneuver stairs independently. The resident remained in this unsuitable environment for two days before being transferred to a general acute care hospital. Facility staff, including the Director of Nursing and Administrator, acknowledged that proper assessment and communication regarding the discharge location and the resident's needs did not occur.
Delay in Incontinence Care and Compromised Resident Dignity
Penalty
Summary
Staff failed to provide timely incontinence care for a resident who was always incontinent and required substantial to maximal assistance with toileting hygiene. The resident, who was cognitively intact and had a diagnosis of hereditary spastic paraplegia, reported being changed at approximately 3 p.m., became wet again about 30 minutes later, and notified staff but remained wet for about an hour. During this period, a strong urine odor was observed in the resident's room. The CNA acknowledged the resident was wet but left the room twice without providing care, only returning to change the resident after a significant delay. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that the expectation was for incontinence care to be provided every two hours and as needed, with communication to the resident if there was a delay. Facility policy emphasized the importance of promptly responding to resident requests for toileting assistance and maintaining resident dignity. The observed delay in care did not align with these expectations and resulted in the resident remaining in a soiled brief for an extended period.
Failure to Ensure Timely Reordering and Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure the timely reordering and availability of a prescribed controlled pain medication, oxycodone, for a resident with chronic gout and a history of multiple gout attacks. The resident was admitted with decision-making capacity and had a physician's order for oxycodone 5 mg, two tablets by mouth every four hours for pain management. A refill request for 48 tablets was submitted and delivered, but based on the prescribed dosing schedule, the supply would have been depleted by June 25. There was no documentation that a refill was requested before the supply ran out, resulting in a missed scheduled dose on June 26, as documented in the Medication Administration Record and nursing notes. Interviews with nursing staff and review of facility policies revealed that nurses were expected to request medication refills when three to six doses remained, and best practice was to fax refill requests three to five days before depletion. However, the licensed nurse did not request a refill in time, and when the medication ran out, there was no oxycodone available in the emergency kit. This led to the resident missing a scheduled dose of pain medication, as confirmed by both the resident and staff interviews.
Dietary Staff Did Not Follow Quat Sanitizer Test Instructions
Penalty
Summary
The facility failed to ensure dietary staff were able to safely and effectively carry out food and nutrition services when a dietary aide did not perform testing of the sanitizing solution in accordance with the manufacturer instructions. During a concurrent observation and interview on December 10, 2025, the dietary aide demonstrated the sanitation testing process using Quaternary test paper by dipping the strip into the sanitizing solution, counting to 15 seconds, and then comparing it to the color chart. The aide stated the acceptable range should be between 200 and 400 ppm to ensure effectiveness. A review of the sanitation strip container labeled [brand name] Quat test paper showed the strip should be immersed in the sanitizing solution for 10 seconds and immediately compared to the color chart. On December 11, 2025, the Registered Dietitian stated the quaternary test paper was used to test the concentration of the quaternary sanitizing solution for dishwashing and confirmed the strips should be immersed for 10 seconds in accordance with manufacturer instructions. The [Brand Name] (QT-40) Quat Test Paper instructions also indicated the strip should be dipped into the sanitizing solution for 10 seconds and instantly compared to the enclosed color chart.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat residents with dignity and respect for three residents reviewed for dignity. Resident 123 was observed waiting for her lunch while her roommate was already eating, and CNA 2 later stated that Resident 123 should have received her meal at the same time as her roommate. LVN 2 and the DON stated that residents in the same room are expected to receive and eat their meals at the same time so dignity is maintained. The facility policy for assisting residents with in-room meals stated that everyone should be served. Resident 6 was observed with a Foley catheter drainage bag hanging below the bed, uncovered and exposed to other residents and visitors. CNA 1 confirmed the bag was not covered with a dignity bag, and the DON stated all Foley bags should be covered for dignity. Resident 124, who was admitted with altered mental status, was observed when an LVN entered the room without knocking. The LVN stated he did not knock and should have done so, and the DON stated staff should knock before entering residents' rooms to respect privacy and dignity. The facility policy stated residents are treated with dignity and respect at all times and staff are expected to knock and request permission before entering residents' rooms.
Failure to Provide Bed-Hold Notice at Transfer
Penalty
Summary
The facility failed to provide written notice of bed hold to Resident 3 or the resident representative at the time of transfer to an acute care hospital. Resident 3 was admitted to the facility on July 7, 2022, with diagnoses including depression (mood disorder). On December 6, 2025, a nurse progress note documented that the resident departed the facility at approximately 8:40 a.m. and was sent to a hospital for further evaluation while alert and verbally responsive. A review of the facility's Bed Hold - Informed Consent - Confirmation of Transfer and Bed hold Provision form showed the sections for the transferred resident, person notified, and 24-hour notification were left blank, and there was no documented evidence that written bed-hold notification was provided at the time of transfer. During interview, LVN 4 stated she did not notify the resident about the bed-hold policy at the time of transfer and acknowledged the form should have been completed. The DON stated licensed nurses are expected to complete the bed-hold notification form at admission and again at the time of transfer to ensure residents' bed hold rights are honored and to prevent inappropriate discharge.
Meal Tray Misidentification and Missed Oxygen Tubing Change
Penalty
Summary
Staff failed to properly identify Resident 51 before serving the breakfast tray. Resident 51 stated the tray initially served had another resident’s name on the meal ticket and was not intended for him. Resident 51’s record showed an admission date of June 11, 2025, with diagnoses including dementia, and his history and physical indicated he had the capacity to make decisions. His physician orders called for a regular diet with regular texture and thin consistency. CNA 3 stated she was distracted and did not correctly identify Resident 51’s full name using the meal ticket when serving breakfast, and acknowledged the tray served to Resident 51 was intended for Resident 91, whose orders were for a regular, no added salt diet with minced and moist texture, thin consistency, and a 1200 ml fluid restriction. Staff also failed to change Resident 1’s nasal cannula on a weekly basis. Resident 1 was observed receiving oxygen at 2 L/min via nasal cannula, and the tubing was not labeled with a date showing when it had last been changed. Resident 1 stated she used oxygen continuously, and her physician orders included continuous oxygen at 2 L/min via nasal cannula. LVN 2 observed that the tubing had the number 11 written on it and stated it had not been changed weekly in accordance with facility standards of practice. The ADON stated oxygen tubing should be changed weekly on Wednesdays and as needed, and that the licensed nurse should have changed the nasal cannula in accordance with facility practice.
Failure to Maintain Resident Fingernail Hygiene
Penalty
Summary
The facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene when staff did not clean and trim Resident 6’s fingernails. Resident 6 was admitted with diagnoses including dementia and diabetes. During observation, Resident 6 was sitting on the bed awake with fingernails that were long and yellowish in color. A CNA stated the fingernails were long and yellow and should have been cleaned and trimmed to prevent infection. Interviews with an LVN, the DSD, and the DON indicated that CNAs and LVNs were responsible for checking residents’ fingernails and providing daily hygiene care, including cleaning fingernails. The DSD stated the fingernails should have been maintained by offering to clean or file them to prevent scratching, injury, or infection, and noted there was no documentation explaining why the fingernails were kept long. The resident’s care plan identified a self-care deficit related to dementia, limited mobility, limited ROM, and musculoskeletal impairment, with staff participation required for personal hygiene and oral care. The facility policy stated nail care includes daily cleaning and regular trimming to keep nails trimmed and prevent infections.
Medication Documented as Given Before It Was Received
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for Resident 49 when Nuedexta was documented as administered on December 7, 2025, even though the medication was not received by the facility until December 9, 2025. Resident 49 was admitted with anxiety disorder, had an MDS Brief Interview of Mental Status score of 13, and was described as cognitively intact. The physician’s order required Nuedexta 20-10 mg, 1 capsule by mouth twice daily for pseudobulbar affect emotional outbursts. The MAR showed missed doses on December 4, 5, 6, and 7 for the 9 a.m. dose, and on December 8 and 9 for the 9 a.m. dose. The MAR also showed Nuedexta documented as administered on December 2 and 3, December 7 at 9 p.m., December 9 at 9 p.m., and December 10 and 11. Nursing notes documented that the medication had not arrived from the pharmacy, that doses were missed because it was not delivered, and that the medication was pending due to insurance non-coverage requiring authorization. Notes also stated the medication was awaiting delivery from the resident pharmacy via mail and was not available. During interview and record review, LVN 6 stated the medication was not available from December 5 to 8, 2025, and that she could not locate it as being available on the morning of December 8. The DON stated the process for mailed medications was for the nurse to note the delivery time, mark the bottle with the open date, and administer it at the next scheduled time. The DON also stated the medication appeared to have been given on the evening of December 7, but the facility could not identify a bottle or bubble pack with the medication prior to receiving it on December 9, 2025. The facility policy stated medications are to be administered in accordance with prescriber orders and that the date opened is recorded when opening a multi-dose container.
Physician Did Not Address CP Recommendation for Buspirone GDR
Penalty
Summary
The facility failed to ensure the physician reviewed and addressed the Consultant Pharmacist’s monthly medication regimen review recommendation for one resident. Resident 13 was admitted with diagnoses including dementia and bipolar disorder, and the history and physical noted fluctuating decision-making capacity. In October 2025, the Consultant Pharmacist recommended that, if clinically appropriate, the physician consider a gradual dose reduction of buspirone 20 mg three times daily with the eventual goal of discontinuation. The resident’s record did not show documentation that the physician reviewed, accepted, or rejected the recommendation. During a concurrent interview and record review on December 11, 2025, the ADON stated the Consultant Pharmacist recommendation was received by email on November 10, 2025, and the DON stated there was no documented evidence that the recommendation was communicated to the physician upon receipt. The facility policy stated that medication regimen reviews are to be completed monthly, involve review of the resident’s medical record, and that the attending physician documents in the medical record that the irregularity has been reviewed and what action, if any, was taken.
Failure to Use Required PPE for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for Resident 93 when LVN 5 provided direct bedside care without wearing the required gown. On December 10, 2025, an EBP sign was observed posted outside the resident’s room, but LVN 5 was observed inside the room administering oral medications, eye drops, and a breathing treatment without a gown. During interview, LVN 5 stated the resident was on Enhanced Barrier Precaution and acknowledged not wearing PPE while providing those services. Resident 93’s record showed admission with diagnoses including a stage 3 pressure ulcer of the sacral region. The medical record also included an order for infection precautions with Enhanced Barrier Precautions due to wounds, and the care plan identified the resident as at risk for MDRO infection due to wounds, with interventions including use of gloves and gowns during high-contact activities and wound care. The facility policy stated that Enhanced Barrier Precautions require targeted gown and glove use during high-contact resident care activities. The Infection Preventionist and DON both stated staff were expected to wear the required PPE in rooms designated for EBP and that LVN 5 should have worn a gown during bedside care.
Excess Residents Assigned to a Shared Room
Penalty
Summary
The facility failed to ensure that one bedroom, room [ROOM NUMBER], did not accommodate more than four residents. During the initial tour on December 8, 2025, surveyors observed five residents assigned to the room: Residents 13, 45, 47, 60, and 113. Review of the facility’s room size record showed that room [ROOM NUMBER] measured 440.94 square feet, which provided 88.18 square feet per resident. During the survey period from December 8, 2025, to December 11, 2025, no adverse effects impacting the residents’ quality of life were observed, and interviewable residents in the room stated they were comfortable and had no desire to change rooms. A continuation of the room waiver was recommended.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Noncompliance with Puree Diet Order for Resident with Dysphagia
Penalty
Summary
A resident with a diagnosis of dysphagia and a physician-ordered fortified puree diet with nectar/mildly thick liquids was given cotton candy by the Business Office Manager. The resident's care plan and dietary profile both specified the need for a puree texture diet due to swallowing difficulties, and the goal was to ensure safe consumption of food without signs of aspiration. Despite these orders, the Business Office Manager provided the resident with cotton candy after previously asking the former DON if it was permissible. The Registered Dietitian confirmed that the resident should not have been given cotton candy, and the Assistant Director of Nursing stated that staff should communicate with nursing before providing any treats or snacks to residents on special diets. The incident was observed by an LVN, who noted the resident consuming cotton candy and confirmed the resident was at high risk for aspiration. The facility's policy on therapeutic diets required that snacks be compatible with the prescribed diet. The failure to adhere to the prescribed puree diet and provide food in the appropriate form as ordered by the physician resulted in a deficiency, as it placed the resident at risk for choking or aspiration.
Call Light Inaccessibility Due to Improper Placement
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction (stroke) and contracture of the left upper arm was found to have their call light placed on their weaker, left side. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status score of 14. During an unannounced visit, surveyors observed the call light clipped to the left bedrail, making it inaccessible to the resident due to their physical limitations. Interviews with facility staff confirmed that the call light should have been placed on the resident's stronger, right side to ensure accessibility. The CNA acknowledged placing the call light on the weaker side, and the LVN confirmed that the resident would not be able to call for help if the call light was not on the strong side. The resident's care plan and facility policy both required that the call light be accessible to the resident when in bed, but this was not followed in this instance.
Linen Shortage Leads to Delayed Care for Residents
Penalty
Summary
The facility failed to provide adequate linens for two residents, leading to potential delays in care and unmet needs. On February 13, 2025, Resident 2 reported having to wait to be changed or showered due to a lack of linens, washcloths, and towels. Similarly, Resident 3 expressed that she had to wait for these items to become available before receiving care. Observations of the linen closets in nursing stations one and two revealed a complete absence of linens, washcloths, and towels. Licensed Vocational Nurse (LVN) 1 confirmed receiving multiple complaints from Certified Nurse Assistants (CNAs) about the inability to provide care due to the linen shortage, which had been ongoing for one to two months. Interviews with LVN 2, CNA 2, and CNA 3 further corroborated the ongoing linen shortage, causing delays in resident care. The Housekeeping Manager (HM) and Central Supply (CS) also acknowledged the lack of extra linens and the absence of an invoice or receipt for a recent order placed two weeks prior. The Director of Nursing (DON) confirmed the limited availability of linens and stated that the shortage had been reported over a month ago. Despite the facility's policy to provide a comfortable and homelike environment, there was no specific policy regarding linen quantity, although the expectation was to have sufficient supplies to prevent delays in care.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete post-dialysis assessments for a resident on two separate occasions, December 27, 2024, and December 31, 2024. This oversight involved a resident who was admitted with diagnoses including end-stage renal disease and diabetes mellitus. The absence of these assessments was confirmed during a review of the resident's Dialysis Communication Record, which showed no documentation of the resident's condition following hemodialysis treatment on the specified dates. Interviews with facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, revealed that the post-dialysis assessments were missing, and it was acknowledged that this could lead to staff being unaware of critical health changes in the resident. The facility's policy on dialysis care emphasized the importance of communication and documentation, which was not adhered to in this instance, as the necessary post-dialysis assessments were not completed and documented in the resident's medical record.
Failure to Provide Hand Hygiene Before Meal
Penalty
Summary
The facility failed to provide proper hand hygiene to a resident before a meal, which could potentially expose the resident to bacterial contamination. During an observation of lunch service, a CNA was seen serving lunch to a resident without offering or providing hand wipes or any form of hand hygiene. The resident, who had red residue under the fingernails, was allowed to touch and eat the food without cleaning their hands. This action was contrary to the facility's process, which requires residents to perform hand hygiene before meals to prevent the spread of germs and infection. The resident involved in this incident was admitted to the facility with diagnoses including end-stage renal disease, blindness in both eyes, and osteomyelitis. During interviews, both the CNA and the Assistant Director of Nursing acknowledged the failure to provide hand hygiene, which is a part of the facility's policy and procedure. The facility's policy, dated September 18, 2023, emphasizes hand hygiene as the primary means to prevent the spread of infections, and all personnel are expected to follow these procedures to protect residents, staff, and visitors.
Failure to Post Current Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was accessible to residents and visitors, as required by their policy. During an unannounced visit, surveyors observed that the staffing information was hidden, having fallen between the front glass window and the receptionist desk. The Director of Staff Development (DSD) confirmed that the staffing information should be posted in a visible area daily at the start of each shift. Additionally, the posted staffing information was outdated, reflecting data from December 31, 2024, instead of the current date. The facility's policy mandates that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel responsible for resident care should be posted in a prominent location accessible to residents and visitors.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident A, when pork loin was served on their dinner tray despite clear instructions indicating 'NO PORK' on the meal ticket. This incident was not isolated, as Resident A reported that it had occurred multiple times in the past. The resident's admission record and nutritional assessment both documented a preference for no pork due to cultural, religious, or ethnic reasons. The Registered Dietitian confirmed that the facility's practice is to honor residents' preferences, and the Dietary Service Supervisor stated that the meal ticket should have been followed. Interviews with the cook revealed a lack of awareness regarding the resident's dislike for pork, suggesting a possible misreading of the meal ticket by dietary staff. The facility's policy, titled 'Resident Food Preference,' mandates that meals be consistent with residents' preferences, yet this was not adhered to in Resident A's case. The failure to follow the documented dietary preferences had the potential to result in the resident eating less or skipping meals, which could lead to weight loss.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to conduct a self-administration assessment for a resident who was self-administering medication. During an observation and interview, the resident was found with two clear cups containing a clear gel, identified as A&D ointment, on their bedside table. The resident stated they used the ointment for scratches on their arms and that the licensed nurses were aware of this practice. However, a review of the resident's medical records revealed that no assessment had been conducted to determine the safety and appropriateness of self-administration. An LVN confirmed that an assessment should have been completed prior to allowing the resident to self-administer medication. The facility's policy requires an interdisciplinary team to assess a resident's cognitive and physical abilities before permitting self-administration of medications.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were discarded and not readily available for use, as observed during a survey. On October 16, 2024, during an observation and interview with an LVN at Station One, multiple expired medications were found in the medication cart. These included Gabapentin 100 mg capsules with an expiration date of May 21, 2024, Tramadol HCL 50 mg tablets with an expiration date of October 9, 2024, and Dicyclomine 20 mg tablets with an expiration date of October 12, 2024. The LVN acknowledged that these medications were expired and should have been removed from the cart and either destroyed or given to the DON for disposal, especially in the case of narcotics. The ADON confirmed that expired medications should be removed from medication carts and disposed of in a destruction bucket to ensure resident safety and prevent the administration of expired medications, which could lead to adverse reactions. The facility's policy, dated April 2008, states that outdated, contaminated, or deteriorated medications should be immediately removed and disposed of according to procedures for medication disposal. This oversight in medication management had the potential to result in the administration of expired medications to residents.
Deficiencies in Dietary Staff Training and Food Safety Procedures
Penalty
Summary
The facility failed to ensure that two dietary staff members were adequately trained to provide proper nutrition services for 95 residents. The Dietary Aide was observed testing the concentration of the chlorine sanitizing solution incorrectly by not following the manufacturer's instructions, which required a quick dip, immediate blotting, and comparison to a color chart. Instead, the Dietary Aide dipped the strip for five seconds and misread the concentration as 200 ppm, while the correct range should have been 50-100 ppm. The Registered Dietician confirmed that not following the manufacturer's instructions could lead to foodborne illness, and the facility's document on sanitization emphasized maintaining the correct chemical concentration according to guidelines. Additionally, the Cook was unable to verbalize the proper cool down process for food, stating that warm food should be placed directly into the refrigerator for five hours. This contradicted the facility's policy, which required cooling from 135°F to 70°F within two hours and then to 41°F or below within the next four hours. The Dietary Manager confirmed the correct cool down process and acknowledged the potential for foodborne illness if not conducted properly. The facility's policy on food preparation and service highlighted the importance of rapid cooling for potentially hazardous foods, specifying the total cooling time should not exceed six hours.
Infection Control Deficiencies in Wound Care and PPE Usage
Penalty
Summary
The facility failed to implement proper infection control measures during wound care for a resident with a Stage 4 pressure ulcer. During an observation, a Licensed Vocational Nurse (LVN) did not change gloves or perform hand hygiene after removing a soiled wound dressing and before cleaning the wound. This lapse in protocol was acknowledged by the LVN and the Assistant Director of Nursing, who confirmed that the correct procedure was not followed, potentially leading to cross-contamination. Additionally, two clean linen closets were found to be unclean, with various items such as unused adult diapers, towels, and dirty gloves littering the floors. The Housekeeping Laundry Supervisor acknowledged that these areas should be kept clean and organized to prevent infection. The facility's policy on infection prevention and control emphasizes maintaining a sanitary environment to prevent the transmission of infections. Furthermore, a licensed nurse failed to wear Personal Protective Equipment (PPE) when entering a transmission-based precaution room for a resident diagnosed with CRE bacteria in the urine. Despite a contact precaution sign being present, the nurse provided care without donning PPE, which was against the facility's policy. The Infection Preventionist confirmed that PPE should have been worn to prevent the spread of infection.
Failure to Ensure Resident Dignity in Care and Meal Service
Penalty
Summary
The facility failed to ensure dignity for two residents, leading to deficiencies in their care. In the first instance, a Certified Nursing Assistant (CNA) did not provide necessary assistance to a resident with Alzheimer's disease who requested help to use the bathroom. Instead, the CNA instructed the resident to use her incontinence pad, contrary to the care plan that required offering a bedpan or bedside commode. This action was acknowledged by the CNA and the Assistant Director of Nursing as a dignity issue, as it did not respect the resident's need for assistance and self-worth. In the second instance, a resident was not served lunch at the same time as other residents at the same table, resulting in the resident watching others eat for approximately twenty minutes. This delay in meal service was confirmed by a Licensed Vocational Nurse (LVN) and a Registered Dietitian (RD), who both stated that meals should be served simultaneously to residents seated together to maintain their dignity and prevent feelings of exclusion. The facility's policy on dignity emphasizes the importance of treating residents with respect and ensuring their well-being and self-esteem.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the California Department of Public Health (CDPH) within the required timeframe. Resident 310, who was admitted with a diagnosis of anxiety, reported feeling threatened and emotionally distressed after an alleged incident where another resident, Resident 30, intentionally bumped into her wheelchair with a walker. This incident was documented in Resident 310's Change in Condition on October 13, 2024. Despite the report being made to the Director of Nursing (DON) and the Administrator by Registered Nurse (RN) 1, the facility did not report the incident to the state survey agency within the mandated two-hour window. The Assistant Director of Nursing (ADON) confirmed that all staff are mandated reporters and should have reported the incident immediately. The facility's policy, titled 'ABUSE PROHIBITION & PREVENTION POLICY AND PROCEDURE,' also stipulates that such allegations must be reported immediately, no later than two hours after the incident.
Failure to Update Care Plan for Resident with CRE Bacteremia
Penalty
Summary
The facility failed to update the plan of care (POC) for a resident, resulting in a licensed nurse being unaware of the resident's current condition and care requirements. During a medication administration observation, a Licensed Vocational Nurse (LVN) was seen entering and exiting the resident's room without using personal protective equipment (PPE), despite a contact precaution sign being present. The LVN admitted to not knowing the reason for the contact precautions. The resident had been readmitted to the facility with a new diagnosis of Carbapenem Resistant Enterobacteriaceae (CRE) bacteremia in the urine, which required contact isolation, but this information was not updated in the resident's POC. The Infection Preventionist (IP) and the Director of Nursing (DON) acknowledged that the POC should have been updated upon the resident's readmission to reflect the new diagnosis and necessary precautions. The facility's policy requires the Interdisciplinary Team (IDT) to update care plans when a resident is readmitted from a hospital stay. However, the IP admitted to not updating the POC, and the DON confirmed that the IDT was responsible for ensuring the POC reflected the resident's specific care needs. This oversight led to a lack of awareness among staff regarding the resident's condition and the necessary interventions.
Lack of Physician Orders for Resident Medications
Penalty
Summary
The facility failed to ensure that two residents had physician orders for medications they were using, which is a requirement according to the facility's medication administration policy. Resident 34 was observed with A&D ointment in his room, which he self-administered for scratches on his arms. Despite the licensed nurses being aware of this, there was no physician order for the ointment in Resident 34's records. This was confirmed by a Licensed Vocational Nurse who acknowledged the absence of a physician order for the ointment. Similarly, Resident 55 was found with a bottle of eye drops on his bedside table, which he used multiple times a day for dry eyes. The eye drops were brought in by a friend, and there was no physician order for them in Resident 55's records. The Director of Nursing confirmed the lack of a physician order for the eye drops, which is contrary to the facility's policy that requires medications to be administered in accordance with written orders from the attending physician.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as a fall risk. On October 16, 2024, during an observation, it was noted that Resident 209, who was lying in bed, did not have a floor mat in place as required by their care plan. The resident had been admitted with diagnoses including altered mental status and unsteadiness on feet, and their care plan, dated June 30, 2024, specified the use of fall mats to mitigate the risk of falls. Interviews with facility staff confirmed the oversight. A Licensed Vocational Nurse (LVN) acknowledged that Resident 209 was a fall risk and confirmed the absence of the floor mat, which was part of the resident's care plan. A Registered Nurse (RN) further confirmed that following previous falls, a floor mat was implemented as an intervention to prevent injury. The facility's policy on comprehensive care plans emphasized the importance of implementing targeted interventions to maintain residents' well-being, which was not adhered to in this case.
Deficiency in Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, as observed during a survey. Resident 34 was seen using a nasal cannula for oxygen delivery, but the tubing was not date-labeled, and the Licensed Vocational Nurse (LVN) was unaware of when it was last replaced. This lack of labeling was confirmed by the Assistant Director of Nursing (ADON), who stated that oxygen tubing should be dated for infection control purposes. Similarly, Resident 59 was observed with a nasal cannula attached to an oxygen concentrator, also without date labeling, which was acknowledged by another LVN and the ADON. Additionally, Resident 59 was using oxygen therapy without a physician's order, which is against the facility's policy. The resident, who has a history of asthma and anxiety, stated she used oxygen as needed. However, a review of her records showed no physician's order for oxygen use, a fact confirmed by the LVN and the ADON. The facility's policy requires verification of a physician's order for oxygen administration, which was not adhered to in this case.
Expired Food Brought by Visitors Not Discarded
Penalty
Summary
The facility failed to ensure that food brought by visitors and family members was not expired and was safe for consumption, potentially exposing residents to foodborne illness. During an observation and interview with the Assistant Director of Nursing (ADON), it was found that food items belonging to a resident were stored in the residents' food refrigerator without proper date labeling. The items included eight cooked hot dogs in ziplock bags, a croissant bread with a past discard date, a turkey provolone and pesto ciabatta sandwich with a past enjoy-by date, and an egg sandwich with a past discard date. The ADON acknowledged that these items should have been discarded as they were unsafe for consumption. The facility's policy indicated that perishable foods should be labeled with the resident's name, the item, and the 'use by' date, and discarded on or before this date.
Failure to Transcribe Physician Order for Contact Isolation
Penalty
Summary
The facility failed to ensure that a physician order was transcribed into the electronic medical record (EMR) for a resident, which had the potential to affect the resident's overall health and well-being. The resident was admitted with a diagnosis of sepsis and required contact isolation due to CRE in the urine. However, the physician order for contact isolation was not transcribed into the resident's EMR. The Infection Preventionist (IP) received the physician order on October 7, 2024, but did not transcribe it into the medical records. During an interview, the IP acknowledged the oversight and stated that the order should have been transcribed in a timely manner to ensure staff awareness of the current orders for resident care. The Director of Nursing (DON) confirmed that physician orders should be transcribed at the time they are received or within four hours, and the facility's policy supports this requirement.
Non-Functioning Call Light for a Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was functioning at all times, which was identified during an observation and interview with Resident 67. On October 17, 2024, at 9:09 a.m., Resident 67 reported that his call light was not working, and this was confirmed when he pressed the call button, but neither the light near the bed nor the dome light outside the room activated. At 9:10 a.m., a Certified Nurse Assistant (CNA) also tested the call light and confirmed it was not working. The CNA acknowledged that Resident 67 used the call light to request assistance and stated it should be fixed immediately. The facility's policy, dated September 2022, requires that call lights be functioning at all times.
Room Over-Occupancy in LTC Facility
Penalty
Summary
The facility failed to comply with regulations by accommodating more than four residents in a single room. During an initial tour, it was observed that room [ROOM NUMBER] housed five residents, exceeding the maximum allowed occupancy. The room measured 440.94 square feet, providing 88.18 square feet per resident, which is below the required space per resident when accommodating five individuals. Despite this, no adverse effects on the residents' quality of life were observed during the survey, and the residents expressed comfort and no desire to change rooms. A continuation of room waiver was recommended.
Failure to Notify Resident's Representative of New Medication
Penalty
Summary
The facility failed to notify the resident's representative when a new medication, Lorazepam, was added to the resident's medication regimen. This oversight was identified during an unannounced visit to investigate a resident rights issue. The resident, who was severely cognitively impaired and under hospice care for kidney cancer, had appointed a representative to make medical decisions on their behalf. Despite this, there was no documented evidence that the representative was informed about the addition of Lorazepam, a psychotropic medication, to the resident's treatment plan. Interviews with the resident's representative and facility staff revealed that the representative was concerned about the resident appearing overmedicated and had not been informed of the new medication. The Assistant Director of Nursing acknowledged that the facility's policy required notifying the representative of new medication orders. The Director of Nursing confirmed that there was no documentation of notification to the representative, despite the resident consenting to the medication. The facility's policy stated that both the resident and their representative should be informed of treatment changes, which was not adhered to in this case.
Failure to Follow Up on Hospice Service Change Request
Penalty
Summary
The facility failed to follow up on a Letter of Agreement (LOA) for hospice services for a resident, resulting in the resident's inability to change hospice providers. The resident, who was readmitted to the facility with a diagnosis of kidney cancer and severe cognitive impairment, was under hospice care. The resident's representative expressed a desire to change hospice providers and had found a new hospice service. However, despite the new hospice reaching out to the facility for approval, there was no response from the facility for over a month. Interviews with facility staff revealed that the Director of Nursing was aware that residents could choose any hospice service, but the responsibility for following up on the LOA approval lay with the Administrator. The Social Services Director reported the request to the Administrator, who admitted to sending the LOA to the corporate office but failed to follow up due to being out of the country and not delegating the task. The facility's policy indicated that social services were designated to coordinate care, but the lack of follow-up on the LOA led to the deficiency.
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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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Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta Vista Healthcare & Wellness Centre | 0.9 mi | ★★★★★ | 6 | 0 |
| Villa Health Care Center | 1 mi | ★★★★★ | 3 | 0 |
| Riverwalk Post Acute | 1.2 mi | ★★★★★ | 21 | 0 |
| Mission Care Center | 1.2 mi | ★★★★★ | 4 | 0 |
| Woodcrest Post Acute & Rehabilitation | 1.7 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.