Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citrus Heights Health Center during CMS and state inspections, most recent first.
A resident who was disoriented, severely cognitively impaired, and fully dependent for ADLs required two-person assist for bed mobility and personal care. A CNA attempted to turn and provide care without waiting for a second staff member, and the resident rolled off the bed and fell, sustaining multiple skin tears, cuts, and abrasions. Staff interviews and the facility investigation confirmed the resident needed two staff for this care and that the CNA did not wait for assistance.
Bedside Medications Kept Without Self-Administration Assessment: Two residents had medications left at the bedside without documented physician authorization or an assessment confirming they could safely self-administer. One resident kept an inhaler and eye drops at the bedside and was seen using the inhaler, while another kept hydrocortisone cream at the bedside and self-applied it for a facial rash. The records showed respiratory and skin-related orders, but the facility did not ensure the medications were controlled in accordance with its self-administration policy.
A facility failed to act on pharmacist MDRR recommendations for three residents. One resident with bipolar disorder had a GDR recommendation for antipsychotic therapy that was not documented as communicated to the physician, another resident with depression had a Remeron GDR recommendation without documented physician rationale or evidence the recommendation was found in the chart, and a third resident had a pharmacist recommendation for a lipid panel that was left blank and not found in the record. The DON acknowledged the missed follow-up on these pharmacist recommendations.
Unsigned Consent for Mirtazapine: A resident with depression and intact cognition was ordered Mirtazapine 15 mg nightly, but the consent form remained pending the physician’s signature. The IPN stated the consent had been completed and was awaiting the physician, and the DON said the form had been flagged but missed, with Medical Records not faxing it to the physician until later. The facility policy required written informed consent for psychoactive medications.
Missed Admission MDS Completion: The facility failed to complete an admission MDS for a resident who returned from the hospital and then rapidly deteriorated with SOB and respiratory distress, requiring transfer back to the hospital the same night. The MDS nurse stated no admission MDS was completed for the re-admission, and the last MDS in the system was from an earlier stay.
Inaccurate MDS Diagnosis Coding: A resident’s MDS coded bipolar disorder as an active diagnosis even though the DON confirmed it was only a historical diagnosis. The resident’s H&P listed UTI, pyelonephritis, chronic anxiety disorder, and chronic migraine headaches, and the IPE identified anxiety disorder only. The MDS also documented intact cognition, supervision or touching assistance with ADLs, and substantial/maximal assistance with mobility, but it did not accurately reflect the resident’s active psychiatric status.
GT Feeding Not Maintained Per PO: A resident with hemiplegia, gastrostomy, and severe cognitive impairment was observed receiving Jevity 1.5 via GT outside the ordered schedule. RN and DON confirmed the PO required the feeding to be turned off at 10 am and turned on at 2 pm, but it was still infusing at 11:20 am and 12:38 pm. The resident's CP directed tube feeding be administered as ordered by the physician.
Inaccurate PASRR Documentation for a Resident with Psychiatric Diagnoses: The facility inaccurately documented PASRR Level 1 screening for a resident with schizophrenia, bipolar disorder, and major depression. The resident’s record also showed cognitive impairment, inability to make medical decisions, and an order for Fluoxetine for major depressive disorder, yet the PASRR marked no serious mental illness. The DON acknowledged the screening was inaccurately reflected.
Call Light Not Within Reach: A resident with intact cognition and decision-making capacity was observed in bed with a call light pad positioned near the head, but she could not press it when she needed assistance. A CNA tested the call light and the resident was unable to activate it until the pad was moved closer to her head, after which the CNA assisted with wiping her nose. The facility policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not upheld by the facility.
Three residents did not receive appropriate care due to failures in monitoring for bleeding while on anticoagulant therapy, lack of adherence to hospice physician orders and coordination, and insufficient evaluation and education regarding diabetes management prior to discharge. These deficiencies included missing documentation, unclear responsibilities between facility and hospice staff, and inadequate discharge planning and teaching.
Surveyors found five cups of orange-colored frozen food in the kitchen freezer that were not labeled or dated, and the Dietary Supervisor could not identify the contents or preparation date. Facility policy requires all stored food items to be labeled and dated.
The facility did not submit required direct care staffing data for a quarter through the PBJ system due to a transition in the controller position and lack of a submitter ID for the new controller, resulting in noncompliance with CMS reporting requirements.
A resident admitted with multiple medical conditions had their initial comprehensive MDS assessment completed, but the facility failed to submit the assessment to CMS within the required 14-day timeframe. Staff interviews and record reviews confirmed the late submission, which did not comply with federal requirements for timely MDS data transmission.
A resident with schizophrenia, bipolar disorder, and major depression was admitted and receiving psychotropic medication, but the facility failed to complete the required PASARR screening before or after admission. Review of records and staff interviews confirmed that only an outdated PASARR was on file, and no current screening was conducted as mandated by facility policy.
A resident with a PICC line in the left upper arm had blood drawn by venipuncture from the same arm, despite facility policy and national guidelines advising against this practice. The laboratory staff did not communicate with nursing staff or receive reminders to avoid the arm with the PICC line, leading to a deficiency in following professional standards of nursing practice.
A resident who was fully dependent on staff for self-care, nonverbal, and receiving enteral feeding was observed with dry, chapped, and cracked lips, indicating inadequate oral hygiene. Staff interviews revealed that oral care was not consistently provided because the resident did not eat orally, despite facility policy requiring assistance with ADLs and maintenance of personal and oral hygiene for all dependent residents.
A resident with diabetes and end stage renal disease was discharged home without prior confirmation that Home Health nursing services for diabetes management were arranged, as the Social Services Director did not confirm with the agency before discharge, resulting in a lapse in continuity of care.
A facility failed to identify a potential chemical restraint for a resident by having a physician order for Ativan if the resident attempted to get out of bed unassisted. The resident had multiple diagnoses, including muscle weakness and cerebral infarction, and was dependent on staff for care. The order did not specify a medical symptom that the medication could relieve, potentially restricting the resident's movement for staff convenience. The facility's policy defined chemical restraint as any drug used for discipline or staff convenience, not required to treat medical symptoms.
A facility failed to create a comprehensive care plan for a resident with limited range of motion (ROM) in both lower extremities, despite the resident's dependence on all activities of daily living and diagnoses of dementia and Alzheimer's disease. The lack of a care plan led to a delay in implementing necessary ROM exercises and interventions, which were only started months after admission. This oversight was contrary to the facility's policies requiring a person-centered care plan with measurable objectives.
A facility failed to prevent a decline in ROM for a resident with dementia and Alzheimer's, as no joint mobility assessment was conducted upon admission. The resident experienced a 26-50% loss of ROM in the knees, causing discomfort. Delays in PT evaluation due to communication issues with hospice and lack of ROM exercises until months after admission contributed to the deficiency.
A resident with dementia and Alzheimer's was prescribed Buspirone and Clonazepam for anxiety-related blowing behavior without proper assessment. The facility failed to document the necessity for increased medication dosage or conduct a psychiatric evaluation to determine the behavior's cause. Inconsistent monitoring and lack of comprehensive assessment led to this deficiency.
A facility reported a 16% medication error rate due to a nurse's failure to follow physician orders for a resident with hypertension and rheumatoid arthritis. The nurse did not check the resident's blood pressure and heart rate immediately before administering amlodipine and metoprolol, nor did they provide food with metoprolol and hydroxychloroquine as required. This non-compliance with medication administration protocols was confirmed by the Director of Nursing.
The facility failed to keep two of four garbage dumpster lids closed, as required by their waste disposal policy. This was observed during a survey, with the dumpsters being more than halfway full and located near the skilled nursing facility. The Director of Dietary Services acknowledged the need to keep lids closed to prevent pest attraction. Additionally, a fly was observed in the kitchen, potentially entering through a nearby delivery door.
CNA 3 and the DON failed to wear the required PPE for a resident with an indwelling foley catheter, as per physician orders and facility policy. The resident, with spinal stenosis and neuromuscular dysfunction of the bladder, required enhanced barrier precautions. Observations showed staff not wearing gowns during high-contact care, contrary to infection prevention protocols.
Failure to Provide Required Two-Person Assistance During Bed Care
Penalty
Summary
The facility failed to prevent a fall for a resident who was assessed as high risk for falls, disoriented at all times, severely cognitively impaired, and dependent on staff for all activities of daily living, including bed mobility, transfers, and personal care. The resident’s care plan required two-person assistance for transfers and bed mobility, and the resident was documented as needing two or more helpers for mobility-related care. Facility staff also described the resident as totally dependent and needing two staff for turning and personal care. On the night of the incident, a CNA was providing personal care and attempting to turn the resident in bed without waiting for assistance from a second staff member. According to staff statements and the facility’s investigation, the CNA pulled the resident toward her and turned the resident onto the left side to remove soiled linen from beneath the resident. During this care, the resident rolled off the left side of the bed and fell to the floor. RN 2 was notified shortly afterward, and the resident was found lying on the floor beside the bed. As a result of the fall, the resident sustained multiple injuries, including an open skin flap on the right forearm, a skin tear and open skin flap on the left hand, a cut on the left nostril, a cut on the lip area, and abrasions on the left anterior foot. Interviews with nursing, CNA, rehabilitation, and administrative staff consistently confirmed that the resident required two-person assistance for bed mobility and ADL care, and the facility’s own investigation concluded that the CNA failed to wait for prior assistance despite knowing the resident required two-person assist during ADLs.
Bedside Medications Kept Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure residents were not allowed to keep medications at bedside without a physician's order and/or without being assessed to determine whether they were capable of self-administering medications. This involved two sampled residents, Residents 26 and 38, and the report states the deficient practices had the potential for unsafe medication administration and adverse consequences. Resident 26 was admitted with diagnoses including pleural effusion and heart failure. The record showed orders for inhaled respiratory medications, including Breo Ellipta and albuterol, and the history and physical noted the resident had the capacity to understand and make decisions, while the MDS indicated moderately impaired cognition. During observation, an inhaler and two eye drops, Systane and Visine, were on the bedside table. Resident 26 stated the inhaler was used during coughing spells. A CNA stated the resident kept the eye drops and inhaler at the bedside and had been seen self-administering the inhaler, while the IP nurse stated the inhaler and eye drops were on the bedside table and the facility kept inhalers and eye drops in medication carts unless it was a resident's preference. Resident 38 had diagnoses including sepsis and chronic pain, and the history and physical indicated the resident had the capacity to understand and make decisions; the MDS indicated the resident was cognitively intact. The resident had an order for hydrocortisone cream for facial redness, and the care plan addressed skin problems and infection monitoring. During observation, a tube of hydrocortisone cream was on the bedside table, unsupervised and readily accessible. Resident 38 stated the cream had been brought from home by the resident's son and that the resident had been self-applying it to the face as needed for a mild rash after antibiotics. The resident also stated staff had seen the self-application, but the facility had not been notified about the cream in the resident's possession.
Pharmacist Medication Review Recommendations Not Acted Upon
Penalty
Summary
The facility failed to ensure that irregularities identified in the Monthly Drug Regimen Review were acted upon for three sampled residents. For Resident 2, who was readmitted with diagnoses including bipolar disorder, urine retention, and obstructive reflux uropathy, the record showed orders for Olanzapine, Lithium Carbonate ER, and Lamotrigine. The facility pharmacist documented a recommendation to reevaluate whether a gradual dose reduction was appropriate for the antipsychotic regimen, but the form did not show a clinical rationale for not attempting a GDR, and the DON stated there was no documentation that the physician had been informed of the pharmacist’s recommendation. For Resident 16, who had diagnoses including depression and essential hypertension and was documented as cognitively intact, the physician ordered Mirtazapine 15 mg nightly for depression and sleep. The pharmacist’s medication review noted Remeron 15 mg at bedtime and asked the physician to evaluate whether a GDR was appropriate, but the review did not show that a GDR was attempted or that a physician clinical rationale was documented for not reducing the dose. The record also indicated a follow-through note was written to a secondary physician, but the IP could not find that note in the resident’s record, and the DON stated the facility was waiting for a psychologist appointment and had no response from the psychologist after the appointment. For Resident 39, who had diagnoses including personal history of circulatory disease and major depressive disorder and was documented as cognitively intact, the pharmacist recommended a lipid panel in the monthly review. The physician response was left blank, and the IP could not find a lipid panel in the record. The DON stated the recommendation had been overlooked. Facility policy stated that resident-specific medication regimen review recommendations are to be documented and acted upon, and that the DON/designee shall follow up on all recommendations from the facility pharmacist.
Unsigned Consent for Mirtazapine
Penalty
Summary
The facility failed to ensure that one sampled resident was free from chemical restraints by not ensuring the resident’s consent for Mirtazapine was signed by the physician. Resident 16 was admitted and later readmitted to the facility with diagnoses including depression and lack of coordination. The resident’s MDS dated 5/22/2026 indicated intact cognition, and the H&P dated 2/20/2026 indicated the resident had the capacity to understand and make decisions. A physician’s order dated 2/18/2026 directed staff to administer Mirtazapine 15 mg by mouth nightly for depression manifested by inability to sleep at night. During interviews, the IPN stated the Mirtazapine consent was completed on 5/28/2026 and was still pending the physician’s signature, and the DON stated it could take up to one week for the physician to sign the consent and that the consent had been flagged but missed by the physician. The DON also stated Medical Records could fax the consent to the physician, but that was not done until 6/23/2026. The facility policy stated residents do not receive unnecessary or inappropriate psychoactive medications and that written informed consent must be renewed every six months.
Missed Admission MDS Completion
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for a resident admitted on 3/16/2026 was completed within the required timeframe. Resident 7 had diagnoses including secondary malignant neoplasm of the brain and muscle weakness, and the record showed the resident had been admitted to the facility, transferred to a general acute care hospital, and then returned on 3/16/2026. Interdisciplinary notes documented that the resident arrived at approximately 8:00 PM, developed shortness of breath and rapid respiration later that evening, and then experienced respiratory distress, prompting physician notification and an order to transfer the resident back to the hospital the same night. During record review and interview, the MDS Nurse stated Resident 7 had been initially admitted earlier in March, transferred to the hospital, re-admitted, and then discharged again as an unplanned discharge, and that the resident was never re-admitted after the 3/9/2026 discharge. The MDS Nurse also stated there was no admission MDS completed for the 3/16/2026 re-admission and that the last MDS in the system was dated [DATE]. The facility policy required an admission comprehensive MDS to be completed by admission date plus 13 calendar days, but no MDS was found for the 3/16/2026 admission.
Inaccurate MDS Diagnosis Coding
Penalty
Summary
The facility failed to ensure the accuracy of Resident 10’s MDS when bipolar disorder was coded as an active diagnosis even though it was a historical diagnosis during the assessment reference period. Resident 10 was admitted with diagnoses including UTI, anxiety disorder, and migraines. The H&P later listed active diagnoses of UTI, pyelonephritis, chronic anxiety disorder, and chronic migraine headaches. The MDS indicated Resident 10’s cognition was intact, required supervision or touching assistance with ADLs, and required substantial/maximal assistance with mobility, and it identified both anxiety disorder and bipolar disorder as active diagnoses. The Initial Psychiatric Evaluation identified anxiety disorder as the resident’s psychiatric diagnosis and did not identify bipolar disorder as active. During interview and record review, the DON stated Resident 10’s bipolar disorder was a historical diagnosis and not an active diagnosis. The DON also stated the facility failed to ensure the MDS accurately reflected Resident 10’s active diagnoses in accordance with the CMS RAI User’s Manual, which states active diagnoses are those with a direct relationship to the resident’s current status, treatments, monitoring, or risk during the 7-day look-back period and excludes resolved or inactive conditions.
GT Feeding Not Maintained Per Physician Order
Penalty
Summary
Resident 40, who was re-admitted with diagnoses including hemiplegia following cerebral infarction and gastrostomy, had a history and physical dated 10/13/2025 indicating the resident did not have the capacity to understand and make decisions. The MDS dated 4/3/2026 indicated severe impairment in cognitive skills for daily decision making, that the resident rarely or never understood others, and that the resident required total dependence for transferring, dressing, and personal hygiene. Resident 40's care plan dated 4/14/2026 directed that the resident remain free from complications related to tube feeding by administering tube feeding as ordered by the physician. The physician's order dated 6/9/2026 specified Jevity 1.5 at 50 cc/hour for 20 hours, water flushes of 150 cc every 4 hours, and that the GT feeding be turned on at 2 pm to 3 pm and turned off at 10 am to 11 am every shift. On 6/23/2026 at 11:20 am and again at 12:38 pm, Resident 40 was observed receiving Jevity 1.5 at 50 cc/hour via GT even though RN 1 stated the feeding should have been turned off at 10 am and turned on at 2 pm. The DON stated the tube feeding should have been turned off after 10 am and that the physician order needed to be followed.
Inaccurate PASRR Documentation for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to accurately document the PASRR screening result for one sampled resident who had diagnoses of schizophrenia, bipolar disorder, and major depression. Resident 31’s Profile Face Sheet listed those diagnoses, and the resident was receiving psychotropic medication, including Fluoxetine for major depressive disorder. However, the PASRR Level 1 Screening dated 12/9/2025 marked “No” under serious mental illness, despite the resident’s documented psychiatric history. Additional record review showed Resident 31’s H&P indicated the resident could make needs known but could not make medical decisions, the MDS identified cognitive impairment with active psychiatric/mood disorders, and the physician’s orders included Fluoxetine 20 mg nightly for major depressive disorder manifested by verbalization of lack of self-worth. During interview, the DON stated the PASRR screening was inaccurately reflected because the resident had diagnoses of bipolar disorder, depression, and schizophrenia and was receiving Fluoxetine. The facility policy required new admissions and readmissions to be screened for mental disorder, intellectual disabilities, or related disorders through the PASRR process, and documentation in the medical record to be objective, complete, and accurate.
Call Light Not Within Reach
Penalty
Summary
A working call system was not available within reach for one of ten randomly selected residents, Resident 39. Resident 39’s record showed an original admission and a readmission to the facility, with a diagnosis of personal history of other diseases of the circulatory system. The MDS dated 5/6/2026 indicated a BIMS score of 15, and the H&P dated 5/18/2026 stated that Resident 39 had the mental capacity to understand and make decisions. During a concurrent observation and interview on 6/22/2026 at 10:31 AM, Resident 39 was seen in the room with a call light pad close to the resident’s head and stated that she used her head to press it but was unable to press the call light pad. At 10:35 AM, CNA 2 tested the call light pad and Resident 39 was unable to press it until after the third try, when CNA 2 placed it closer to the resident’s head. CNA 2 then assisted Resident 39 and cleaned her nose. The facility’s policy titled, Answering the Call Light, revised March 2021, stated that when the resident is in bed or confined to a chair, the call light should be within easy reach.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulation. Specific actions or omissions by facility staff that led to this deficiency are not detailed in the report, nor are there descriptions of the residents' medical histories or conditions at the time of the incident.
Failure to Monitor Anticoagulant Therapy, Follow Hospice Orders, and Ensure Diabetes Education at Discharge
Penalty
Summary
The facility failed to provide appropriate care and services for three residents by not ensuring proper monitoring and adherence to physician orders. For one resident on anticoagulant therapy, there was no documented monitoring for signs and symptoms of bleeding in the medication administration records for several months, despite care plans and physician orders requiring such monitoring. Staff interviews confirmed that the monitoring was not scheduled or documented, and the coding on the medication record was incorrect, which could have led to the order being missed. Another resident receiving hospice care had conflicting physician orders between the hospice provider and the facility, with no interdisciplinary team meetings conducted as ordered by the hospice physician. The facility staff did not clarify or follow the hospice physician's orders, leading to confusion about which orders to follow and potentially affecting the resident's plan of care. The facility's policy required coordination with hospice representatives to ensure appropriate care, but this was not done. A third resident, who had diabetes and was being discharged home, did not receive a documented evaluation of their or their family member's knowledge regarding diabetes management, including blood sugar checks and insulin administration. The discharge instructions did not confirm whether the resident or family member understood how to manage diabetes care at home, and there was a lack of timely confirmation with the home health agency regarding post-discharge nursing support. The facility's policy required teaching and discharge instructions to be provided and understood prior to discharge, but this was not ensured.
Unlabeled and Undated Frozen Food Items Found in Kitchen Freezer
Penalty
Summary
During a tour of the facility's kitchen, surveyors observed five cups of an orange-colored frozen substance stored in the walk-in freezer without any labels or dates to identify the contents or indicate when they were prepared or should be used by. The Dietary Supervisor was unable to confirm whether the cups contained ice cream or sorbet and did not know when they had been prepared. Both the cups and the tray they were placed on lacked any labeling or use-by dates. Review of the facility's policies confirmed that all food items, including leftovers, are required to be labeled and dated when stored in the storeroom, refrigerator, or freezer.
Failure to Submit Required PBJ Staffing Data
Penalty
Summary
The facility failed to submit the required direct care staffing information for one of two quarters (Quarter 2) through the Payroll-Based Journal (PBJ) system, as mandated by CMS. This deficiency was identified during a review of the PBJ Staffing Data Report, which showed that no data was submitted for the specified quarter. The facility's policy and procedure required quarterly submission of PBJ data within the specified timeframe, but this was not followed for the quarter in question. During an interview, the Administrator explained that the corporate controller office was responsible for submitting the PBJ data. The previous controller resigned in March, and the new controller had not yet received the submitter ID from the State, resulting in the failure to submit the required data. The Administrator acknowledged the importance of submitting PBJ data for accurate staffing and compliance with regulations.
Failure to Timely Submit MDS Assessment
Penalty
Summary
The facility failed to complete and transmit the initial Minimum Data Set (MDS) assessment in a timely manner for one resident. The resident was admitted with diagnoses including venous thromboembolism, anemia, and insomnia. The resident's initial comprehensive MDS assessment was completed on 3/28/2025, but the submission to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system did not occur until 5/9/2025, which was more than 14 days after the assessment completion date. Interviews with the MDS coordinator and the Director of Nursing confirmed that the MDS entry was submitted late and acknowledged the importance of timely submission to ensure proper communication with CMS regarding the care provided. Review of the MDS RAI Version 3.0 Manual confirmed that MDS assessments must be submitted within 14 days of completion, a requirement that was not met in this instance.
Failure to Complete Required PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to conduct the required Preadmission Screening and Resident Review (PASARR) for a resident with multiple mental health diagnoses, including schizophrenia, bipolar disorder, and major depression. The resident was admitted with these diagnoses and was receiving psychotropic medication. A review of the resident's admission record and Minimum Data Set (MDS) indicated cognitive impairment and a need for maximal assistance with daily activities. Despite these factors, the only PASARR screening on file was dated prior to admission, and no additional screenings were completed before or after the resident's admission. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the facility did not submit a PASARR screening for the resident as required. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders through the PASARR process, regardless of payer source. The absence of a current PASARR screening was acknowledged by facility staff during the review of both paper and electronic records.
Failure to Follow Professional Standards During Blood Draw for Resident with PICC Line
Penalty
Summary
A deficiency occurred when a resident with a PICC line in the left upper arm had blood drawn by venipuncture from the same arm, contrary to professional standards and facility policy. The resident was receiving antibiotics through the PICC line at the time, and a folded gauze dressing was observed below the left elbow, which the resident stated was from a blood draw performed earlier that morning. The facility's Director of Nursing confirmed that blood should not be drawn by needle stick from the same arm as a PICC line, as this could lead to complications. The Infection Prevention Nurse was unable to find any nursing resources supporting the practice of venipuncture on the same arm as a PICC line and noted that laboratory staff did not communicate with facility staff before performing the blood draw. The facility did not provide laboratory staff with reminders or warnings to avoid venipuncture on the arm with the PICC line, and there was no documentation of communication regarding the blood draw. Review of facility policy and national guidelines indicated that venipuncture, peripheral IV insertion, and blood pressure measurements should be avoided on the same arm as a PICC line, and that reminder signs should be placed for healthcare team members. The failure to follow these standards resulted in a deficiency related to professional standards of nursing practice.
Failure to Provide Necessary Oral and Personal Hygiene for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs), specifically personal and oral hygiene, to a resident who was completely dependent on staff for self-care. The resident, who had diagnoses including hemiplegia following a stroke, cognitive communication deficit, and vascular dementia, was nonverbal, unable to make decisions, and received nutrition via a G-tube. Observations revealed the resident had dry, chapped, and cracked lips with flaking, indicating a lack of adequate oral care. Staff interviews confirmed that mouth care was typically provided after meals, but since the resident did not eat orally, this care was not consistently given. Further interviews with facility staff, including a CNA, the Infection Prevention Nurse, and the DON, confirmed that both facility and hospice staff were responsible for providing personal and oral care, regardless of the resident's hospice status. Facility policies required staff to assist residents unable to perform ADLs independently and to maintain personal and oral hygiene. However, the observed condition of the resident's lips and staff statements indicated that these policies were not followed, resulting in the resident not receiving the necessary care to maintain oral hygiene and comfort.
Failure to Confirm Home Health Services Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure that a follow-up for needed Home Health (HH) services was completed and confirmed prior to the discharge of a resident who required ongoing care for diabetes management. The resident, who had moderately impaired cognition and required moderate assistance with personal hygiene and toileting, was diagnosed with diabetes mellitus and end stage renal disease. The Social Services Director (SSD) sent a fax request for a Home Health Registered Nurse (HH RN) to visit the resident at home but did not call to confirm the service with the HH agency before the resident was discharged. The resident was discharged home with a family member before confirmation of the HH RN visit was obtained. The facility's own policy and the Director of Social Services' job description required coordination and confirmation of follow-up care and services prior to discharge. The lack of timely confirmation of HH services prior to discharge resulted in a failure to ensure continuity of care for the resident's diabetes management needs.
Failure to Identify Potential Chemical Restraint
Penalty
Summary
The facility failed to identify a potential chemical restraint for a resident by having a physician order that indicated the administration of Ativan if the resident attempted to get out of bed unassisted. The resident, who was admitted with multiple diagnoses including generalized muscle weakness and cerebral infarction, had moderately impaired cognition and was dependent on staff for bathing and toileting. The resident was also always incontinent of bowel and bladder. The physician's order, dated as of 9/12/2024, allowed for the administration of Ativan, a sedative, without specifying a diagnosis or symptom that the medication could relieve, thus potentially restricting the resident's movement for staff convenience. During an interview and record review, the Director of Nursing acknowledged that the order served to restrict the resident's movement and did not indicate a medical symptom that the medication could relieve. The facility's policy and procedure on identifying involuntary seclusion and unauthorized restraint defined chemical restraint as any drug used for discipline or staff convenience and not required to treat medical symptoms. The policy further stated that the risk of falling is not considered a medical symptom or self-injurious behavior that warrants the use of restraints. This deficiency had the potential to restrict the resident's movement for staff convenience or discipline.
Failure to Develop Comprehensive Care Plan for Resident with Limited ROM
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with limited range of motion (ROM) in both lower extremities. The resident, who was admitted with diagnoses of dementia and Alzheimer's disease, was dependent on all activities of daily living and had functional limitations in ROM. Despite these conditions, there was no care plan in place to address the resident's impaired ROM until several months after admission. The Director of Nursing (DON) confirmed that a care plan should have included interventions such as ROM exercises, monitoring for pain, exercise tolerance, skin integrity, and decline in ROM, but these were not implemented until a physical therapy evaluation was completed months later. Observations and interviews revealed that the resident's knees could only extend up to 90 degrees, indicating a lack of proper intervention since admission. A physical therapist began assessing and implementing ROM exercises only after a significant delay, and training for certified nursing assistants on these exercises started even later. The facility's policies required a comprehensive, person-centered care plan with measurable objectives and timetables, which was not developed for this resident, leading to a potential decline in the resident's ROM.
Failure to Prevent Decline in Range of Motion for Resident
Penalty
Summary
The facility failed to provide necessary services to prevent a further decrease in range of motion (ROM) for a resident, identified as Resident 153. The resident was admitted with diagnoses including dementia and Alzheimer's disease and was dependent on all activities of daily living. The Minimum Data Set (MDS) indicated functional limitations in the resident's lower extremities. Despite these indications, the facility did not perform an assessment of joint mobility upon admission to establish a baseline for monitoring any decline or improvement in ROM, as required by the facility's policy and procedure. The deficiency was further highlighted during observations and interviews with the physical therapist (PT) and the Director of Nursing (DON). The PT noted a significant delay in conducting a PT evaluation due to communication issues with the hospice agency, which was responsible for the resident's care. The PT evaluation eventually revealed a 26-50% loss of ROM in the resident's knees, causing discomfort. The DON confirmed the absence of a joint mobility assessment upon admission and acknowledged the lack of communication with the hospice agency to request an evaluation for physical or occupational therapy. Additionally, a Certified Nursing Assistant (CNA) reported that ROM exercises were not provided to the resident until several months after admission, further contributing to the deficiency.
Failure to Assess and Manage Psychotropic Medication Use
Penalty
Summary
The facility failed to properly assess and manage the use of psychotropic medications for a resident, identified as Resident 153, who was admitted with diagnoses including dementia and Alzheimer's disease. The resident was prescribed Buspirone and Clonazepam for anxiety manifested by persistent blowing behavior. However, the facility did not ensure that the resident was assessed for the use of these medications, nor did they ensure that the increase in Buspirone dosage was justified by clinically significant behavior. The Director of Nursing (DON) acknowledged that the resident was not on these medications upon admission and that the increase in Buspirone dosage was made without proper documentation of the behavior causing discomfort or harm. The Social Services Director (SSD) mentioned that the in-house psychiatrist did not assess the resident, as the resident was not under their care, and the behavior was assumed to be anxiety-related without proper evaluation. Observations showed that the resident exhibited the blowing behavior inconsistently, and there was no documentation to determine if it was a habit or anxiety-related. The facility's policy and procedure on psychotropic medications require documentation of the reason for treatment, expected outcomes, and alternative treatments. However, there was no evidence of a psychiatric consultation or assessment to determine the cause of the resident's behavior. The Medication Administration Record (MAR) showed inconsistent monitoring of the behavior, with a significant increase in episodes over several months, yet no comprehensive assessment was conducted to address the underlying cause of the behavior.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with a reported rate of 16 percent during a medication administration observation. This deficiency involved Licensed Vocational Nurse 1 (LVN 1) who did not adhere to physician orders for Resident 152. Specifically, LVN 1 did not check the resident's blood pressure and heart rate immediately before administering amlodipine and metoprolol, medications used to treat high blood pressure. Additionally, LVN 1 failed to administer metoprolol and hydroxychloroquine with food as ordered, which could lead to potential side effects such as stomach issues. Resident 152, who was admitted with diagnoses of hypertension and rheumatoid arthritis, required specific monitoring and administration instructions for their medications. The physician's orders clearly indicated that amlodipine and metoprolol should be withheld if the resident's systolic blood pressure was below 110 or heart rate was below 60, and that metoprolol and hydroxychloroquine should be given with food. LVN 1's actions did not comply with these orders, as the nurse checked the resident's vital signs an hour before medication administration and did not provide food with the medications. The Director of Nursing confirmed the necessity of following these protocols to prevent medication errors and potential harm to residents.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to ensure that two of four garbage dumpsters had their lids closed, as required by the facility's Policy and Procedure titled 'Non-medical Waste Disposal.' This oversight was observed during a survey, where it was noted that the dumpsters, located in a shed a few meters from the skilled nursing facility, were more than halfway full of garbage with their lids left open. The Director of Dietary Services (DDS) acknowledged that the dumpsters should remain closed to prevent attracting pests such as rats and flies, which could lead to the spread of infectious diseases. Additionally, during observations in the kitchen, a fly was seen flying around, which the DDS suggested could have entered through the delivery door. This door was in close proximity to the kitchen, potentially allowing pests to enter the facility. The facility's Pest Management Service Report was reviewed, and it was noted that staff had been in-serviced regarding the importance of keeping dumpster lids closed. The facility's policy emphasized the need to cover trash receptacles to prevent odor, reduce disease transmission, and avoid attracting insects or rodents.
Failure to Follow Enhanced Barrier Precautions for Resident with Foley Catheter
Penalty
Summary
Certified Nursing Assistant 3 (CNA 3) and the Director of Nursing (DON) failed to adhere to the required personal protective equipment (PPE) protocols for Resident 203, as indicated by the resident's physician orders, signage outside the resident's room, and the facility's policy for Enhanced Barrier Precaution. Resident 203, who was admitted with multiple diagnoses including spinal stenosis and neuromuscular dysfunction of the bladder, had an indwelling foley catheter, which necessitated enhanced barrier precautions. The physician's order specified the use of hand hygiene, gown, and gloves during high-contact care activities due to the presence of the urinary catheter. During observations, CNA 3 was seen brushing Resident 203's teeth and transferring the resident from a wheelchair to the bed without wearing a gown, only using a surgical mask and gloves. Similarly, the DON also handled the resident's indwelling foley catheter without wearing a gown. The Infection Preventionist Nurse confirmed that under enhanced barrier precautions, staff should perform hand hygiene and wear a full gown and gloves during direct touch care to prevent potential infections. The facility's policy and signage also indicated the necessity of wearing a gown and gloves for high-contact activities, which was not followed by the staff.
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What surveyors actually found near you
We read the 5,116 citations issued within 25 miles in the last 12 months — including the 7 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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Covina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Glen Care Center | 1.4 mi | ★★★★★ | 28 | 0 |
| Bayshire San Dimas Post-acute | 1.8 mi | ★★★★★ | 17 | 0 |
| Gladstone Sub-acute And Rehab Center | 2 mi | ★★★★★ | 9 | 0 |
| Glendora Grand, Inc | 2.1 mi | ★★★★★ | 5 | 0 |
| Covina Rehabilitation Center | 2.3 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.