Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Coast Care Convalescent Center during CMS and state inspections, most recent first.
The facility failed to keep AD and POLST documentation consistent for three residents. One resident with COPD and a gastrostomy had a POLST showing an AD while the ADAF said no AD was on file, and the DON and SSD noted the forms conflicted. Another resident’s POLST and ADAF indicated an AD existed, but the AD was not in the chart. A third resident’s record contained an AHCD, yet the AHCD acknowledgement form and SSA still stated no AHCD was present.
The facility failed to develop individualized care plans for three residents with identified needs. One resident with anxiety disorder and major depressive disorder had no care plan for anxiety despite cognitive impairment and lack of decision-making capacity. Two residents who smoked had no smoking care plans, even though one had COPD, schizophrenia, fluctuating capacity, and needed smoking-related safety guidance, and the other had COPD, smoked cigarettes several times a day, and was observed smoking on the patio. Staff and the DON stated smoking and diagnosis-based care plans were needed, but they were not present in the records.
Improper food labeling and storage were observed in the kitchen when expired donuts, sliced ham, and roast beef were found in refrigerators/freezers, along with mayonnaise with an incomplete open date, a dated sliced watermelon, and multiple undated brown lettuce heads. An LTC dietary supervisor and dietary aides were unable to explain the date markings, and one aide stated the refrigerator contents and dates were checked despite the expired items remaining present.
RSV vaccination was not carried out for two residents with significant respiratory and cognitive impairments. One resident had responsible-party consent for the RSV vaccine, but the RIR did not show it was administered, and another resident had no documentation that the vaccine was offered to the resident or responsible party. The DON stated the facility offered RSV vaccination to eligible new admissions, and the facility policy required vaccination of eligible residents in line with CDC guidance, provider orders, and consent.
Call Light Not Within Reach for a High-Fall-Risk Resident: A resident with CVA sequelae and dementia, who was dependent on staff for multiple ADLs and assessed as high risk for falls, was observed resting in bed with the call light hanging behind the bed and not within reach. The DON and CNA confirmed the call light was not accessible, and staff stated it should be within arm's reach for safety, fall prevention, and to allow the resident to call for assistance.
A resident who smoked and had smoking privileges did not have a smoking assessment completed on admission. The resident had COPD, muscle weakness, major depressive disorder, and paranoid schizophrenia, and the record showed fluctuating capacity and need for partial/moderate assistance with several ADLs. The AD and DON confirmed the smoking assessment was not completed and no nursing care plan was initiated to address smoking.
Failure to revise a resident’s care plan after Remeron 7.5 mg was discontinued. The resident had anxiety disorder, major depressive disorder, and moderate cognitive impairment, and the H&P noted the resident lacked capacity to make medical decisions. The IPN and DON stated the care plan should be updated when a medication is discontinued or when there is a change in condition, and the facility policy required care plans to be revised as resident needs change.
Missing Documentation for Ordered Restorative Nursing Care: A resident with COPD, gastrostomy, and contractures was bedbound, non-verbal, and had contracted hands and legs. The resident had orders for splints and passive ROM to the upper and lower extremities on weekdays, but the RAR showed no documentation for several days. RNA said the care was provided and documented in the EMR, while RN verified the documentation was missing and the DON stated that if it was not charted, it was not done.
A deficiency was cited after 19 of 21 resident rooms did not meet the required 80 sq. ft. per resident for multiple-occupancy rooms. The facility requested a room waiver and stated the rooms had enough space for wheelchairs, walkers, medical equipment, and nursing care; surveyors observed adequate room for resident movement, privacy, and staff care, and the DON and a resident both stated the space was sufficient.
Three residents did not have individualized or specific care plans, with care plans lacking details such as medication names and not being updated to reflect changes in condition or treatment. Staff and leadership confirmed that care plans should be specific and resident-centered, but the plans reviewed only included general instructions like 'administer medication as ordered' and were not revised when residents' needs changed.
A licensed nurse did not check or document a resident's heart rate before administering losartan, as required by a physician's order that specified the medication should be held if the heart rate was below 60 BPM. The resident, who had hypertensive heart disease and moderate cognitive impairment, received multiple doses of losartan without the necessary heart rate monitoring, contrary to facility policy and professional standards.
A facility failed to follow its policies on advance directives and POLST for three residents, leading to potential conflicts with their healthcare wishes. One resident's POLST was incorrectly signed by a caregiver from a previous facility, and the legal representative was not informed. Another resident's advance directive was incomplete, lacking documentation and signatures. A third resident's forms were missing critical information, making them incomplete. These deficiencies highlight lapses in adhering to facility policies.
The facility did not post accurate nurse staffing data in the lobby, accessible to residents and visitors, on several occasions. The Director of Staff Development admitted to posting projected rather than actual CNA hours worked. Additionally, staffing information was not posted in the lobby as required, only at the nursing station, contrary to facility policy.
The facility failed to ensure appropriate use of psychotropic drugs for two residents by not identifying specific target symptoms and not attempting gradual dose reductions (GDR) as required. One resident was on Seroquel without specific target symptoms identified, and no GDR was attempted for Paroxetine HCL despite minimal depression symptoms. Another resident was on Zyprexa and Lexapro without documented GDR attempts or specific target symptoms. These failures could lead to inappropriate drug use, affecting residents' well-being.
The facility failed to maintain sanitary conditions in an ice machine, leading to the distribution of contaminated ice to 40 residents. Observations showed black and yellow substances in the machine, which were not cleaned according to the manufacturer's guidelines. Staff interviews revealed improper cleaning procedures, with the Dietary Aide cleaning only the exterior and the Maintenance Worker using bleach instead of the recommended products. The cleaning logs were inaccurately signed off, indicating deep cleaning that did not occur.
A resident with severe cognitive impairment was fed by a CNA standing over them, contrary to the facility's policy promoting dignity by having staff seated at eye level. The DON acknowledged that sitting promotes dignity, but usual practice involved standing, highlighting a policy-practice discrepancy.
A resident with hemiplegia and impaired cognition was at high risk for falls due to the facility's failure to ensure the call light was within reach, as required by the care plan and facility policy. The call light was observed hanging at the foot of the bed, out of the resident's reach, which was acknowledged by the DON during an interview.
A facility failed to include PASRR Level II recommended services in a resident's care plan, despite the resident's diagnoses of COPD and schizophrenia. The DSD was unaware of the need to incorporate these recommendations, contrary to the facility's policy, risking the resident's access to necessary mental health services.
A resident with major depressive disorder experienced a 10% weight loss over three months, but the facility failed to create a care plan to address this issue. Despite the resident's intact cognitive abilities and need for eating assistance, staff were unaware of the weight loss, and no monitoring was implemented. The facility's policy required care plans to be updated with changes in condition, which was not followed.
A facility failed to provide a communication board or system for a resident who only speaks Vietnamese, despite the care plan indicating its necessity. The resident, with diabetes and dementia, was at risk for miscommunication and delayed care. The Director of Staff Development confirmed the absence of such tools, contrary to facility policies requiring communication aids for non-English speakers.
A facility failed to try alternative interventions before installing side rails for a resident, risking entrapment and injury. The resident, with intact cognitive abilities and requiring assistance for movement, requested side rails due to fear of falling. Staff interviews revealed no documentation of alternative methods being attempted, despite the facility's policy requiring such assessments.
A resident was not informed about their medications during a medication pass, as the LVN failed to explain the medications and their purposes, contrary to the facility's policy. The resident, who was cognitively intact and had conditions such as Parkinson's Disease and schizophrenia, received nine medications without any explanation. The DON confirmed that medications should be explained to residents to ensure awareness and prevent errors.
A facility failed to secure medications in a medication cart, leaving them unattended and accessible to residents. A nurse left the cart unlocked and medications on top of it while attending to a resident. The DON confirmed that staff must lock carts and dispose of dropped medications properly, as per facility policies.
The facility did not meet the required square footage for 18 resident rooms, as identified through observations and interviews. Despite a waiver request claiming adequate space, the rooms did not comply with the 80 square feet per resident requirement. Residents and staff reported no issues with space for mobility or care, but the facility administrator confirmed no changes in room sizes or bed occupancy since the last survey.
Advance Directive and POLST Documentation Inconsistencies
Penalty
Summary
The facility failed to implement its policies and procedures for Advance Directives and POLST forms for three sampled residents. For Resident 8, the record showed admission with COPD and a gastrostomy, and the H&P indicated the resident lacked capacity to understand and make decisions and had a surrogate decisionmaker. The MDS indicated the resident was rarely or never understood, and the care plan addressed a communication deficit related to being nonverbal and unable to make self understood or understand others. During a concurrent interview and record review, Resident 8’s POLST dated 11/25/2019 indicated the resident had an AD, while the ADAF dated 7/3/2023 indicated the resident did not have an AD. The DON stated there was no AD in the medical chart and that the POLST and ADAF contradicted each other. The DON stated the POLST should be updated to reflect that Resident 8 did not have an AD, and the SSD stated the information was confusing and should match. For Resident 41, the record showed admission and readmission with diagnoses including osteoarthritis and schizophrenia. The MDS indicated intact cognition, shortness of breath when lying flat, and tobacco use. The POLST and ADAF both indicated an AD dated 8/5/2013 was available and reviewed, and the SSA stated the AD was completed and witnessed by the former SSD. However, the DON stated the AD was not in the medical record and should be available in the chart, and the SSD confirmed the AD was not in the chart even though the forms indicated it existed. For Resident 5, the H&P indicated the resident had capacity to make medical decisions and was on DNR status, and the MDS indicated the resident could make self understood and understand others. The medical record contained an AHCD dated 8/15/2022, but the AHCD Acknowledgement Form dated 7/28/2025 and the SSA dated 10/20/2025 both indicated the resident did not have an AHCD. The DON stated the acknowledgement form should have been updated to indicate the resident did have an AHCD on file.
Failure to Develop Individualized Care Plans for Anxiety and Smoking Needs
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for three sampled residents. Resident 40 was readmitted with diagnoses including anxiety disorder and major depressive disorder, and the H&P stated the resident did not have the capacity to make medical decisions. The MDS indicated moderate cognitive impairment, anxiety disorder, and antipsychotic medication use, but during record review there was no care plan for anxiety disorder in the clinical record. IPN 1 stated the resident had a diagnosis of anxiety and explained that an individualized care plan should be developed on admission and based on the resident’s diagnoses. Resident 34 was admitted and readmitted with diagnoses including COPD, muscle weakness, and paranoid schizophrenia. The H&P indicated fluctuating capacity to understand and make decisions, and the MDS showed the resident required partial/moderate assistance with oral care, toileting and personal hygiene, showering, dressing, and footwear. During review of the paper and electronic medical record, there was no smoking care plan for Resident 34. LVN 1 stated a smoking care plan was important as a guide for staff and to identify residents at risk of causing a fire or harm due to physical or cognitive limitations while smoking. The DON stated that when a resident is a smoker, the AD should complete a smoking assessment and nursing staff should initiate the smoking care plan, but in this case the AD did not complete the assessment and there was no smoking care plan or interventions initiated. Resident 41 was admitted and readmitted with diagnoses including osteoarthritis and schizophrenia. The MDS indicated intact cognition, shortness of breath when lying flat, and tobacco use, and the smoking assessment indicated the resident smoked. The H&P stated the resident had COPD and did not have the capacity to understand and make decisions. The resident stated he smoked cigarettes four times a day and needed to leave the room to smoke, and he was observed smoking on the smoking patio. The AD stated Resident 41 did not have a smoking care plan, and the DON stated the resident was a smoker and should have had a smoking care plan to provide interventions for safety and to prevent respiratory problems or other conditions from smoking.
Improper Food Labeling and Storage in Kitchen Refrigerators
Penalty
Summary
The facility failed to follow proper food storage and handling practices in the kitchen. During observation of Refrigerator 1, surveyors found four boxes of variety pack donuts with a use-by date of 12/16/25, one pack of sliced ham in the freezer with a sell-by date of 11/10/25, and two packs of premium roast beef in the freezer with a sell-by date of 10/30/25. A Dietary Aide stated the donut date meant the product was expired and could not be served to residents, and the Dietary/Environmental Supervisor stated it was important not to serve expired food because residents could get sick if served expired food. The Dietary Aide who had initials on the refrigerator checklist stated the contents and dates were checked, but the expired items were still present. During further observation of Refrigerator 2, surveyors found a yellow plastic container of whole egg mayonnaise with an incomplete open date, a sliced watermelon dated 12/18/25, and multiple brown-colored lettuce heads that were undated. The Dietary/Environmental Supervisor and a Dietary Aide were not able to state what the dates indicated, and the supervisor could not state the facility's policy regarding perishable food shelf life. The facility's policy on produce storage indicated melons are stored in the refrigerator for 5-7 days, and the food storage policy stated food items will be stored, thawed, and prepared in accordance with good sanitary practice and correctly labeled and dated.
RSV Vaccination Not Administered or Offered to Eligible Residents
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility did not ensure its RSV policies and procedures were carried out for two sampled residents. Resident 5 was admitted with diagnoses including encephalopathy, DM, and immunodeficiency. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed severely impaired cognition and wheelchair use. A progress note documented coughing and congestion with breathing treatments and cough syrup being given. During review with the IPN, Resident 5’s VCF showed the responsible party consented to RSV vaccination, but the RIR did not show that the RSV vaccine was administered. Resident 6 was admitted with diagnoses including pleural effusion, immunodeficiency, and respiratory disorders. The H&P stated the resident lacked capacity due to dementia, the care plan identified respiratory disorder and pleural effusion with risk for shortness of breath and respiratory distress, and the MDS showed moderately impaired cognition. During review with the IPN, the RIR did not show RSV vaccination was administered, and there was no documentation that the vaccine was offered to Resident 6 or the responsible party. The DON stated the facility offered RSV vaccination to eligible new admissions and that offering it was important for patient safety. The facility policy stated RSV vaccination was to be offered to eligible residents in accordance with CDC recommendations, provider orders, and resident consent.
Call Light Not Within Reach for a High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 43. Resident 43 was admitted and later re-admitted with diagnoses including sequela cerebral infarction and dementia, was assessed as high risk for falls, and was dependent on staff for eating, oral hygiene, upper and lower body dressing, personal hygiene, toileting hygiene, showering, and putting off footwear. The resident's H&P indicated the resident did not have the capacity to understand and make decisions. The care plan, initiated and revised in late December 2025, included an intervention to keep the call light within reach because of fall risk related to unsteady or impaired balance. During observation in the resident's room, Resident 43 was resting in bed and the call light was not within reach; the cord was hanging at the back of the bed. The DON observed and stated the call light was behind the bed and not within reach, and staff interviews confirmed the call light should be within arm's reach for safety, fall prevention, and to allow the resident to call for assistance. The facility's policy on call lights stated that call lights should be positioned conveniently and within reach for the resident to use.
Missing Smoking Assessment for Resident with Smoking Privileges
Penalty
Summary
The facility failed to ensure an accurate assessment was completed for one of two sampled residents, Resident 34, who smoked. Resident 34’s admission record showed an initial admission and a readmission, with diagnoses including COPD with exacerbation, muscle weakness, major depressive disorder, and paranoid schizophrenia. The admission checklist dated 10/24/25 did not indicate that a smoking assessment was completed, and the history and physical dated 10/26/2025 noted fluctuating capacity to understand and make decisions. The MDS dated 10/30/2025 showed Resident 34 required partial/moderate assistance with oral care, toileting, personal hygiene, showering, upper and lower body dressing, and footwear. During record review on 12/31/2025, there was no smoking assessment completed for Resident 34. LVN1 stated that a smoking assessment was important for staff guidance and resident safety, including identifying hazards such as burns or fire and determining whether residents were safe to smoke. The AD stated Resident 34 was a smoker and had smoking privileges, and that smokers are provided a smoking assessment and smoking policy on admission. The DON stated that when a resident is admitted as a smoker, the AD should complete a smoking assessment and nursing staff should initiate a care plan, and confirmed that the smoking assessment for Resident 34 was not completed and no care plan was initiated to address smoking.
Failure to Revise Care Plan After Antidepressant Discontinued
Penalty
Summary
The facility failed to revise Resident 40’s Comprehensive Care Plan after Remeron 7.5 mg, an antidepressant used to treat depression, was discontinued. Resident 40 was readmitted to the facility with diagnoses including anxiety disorder and major depressive disorder, and the H&P indicated the resident did not have the capacity to make medical decisions. The MDS dated 9/25/25 indicated moderate cognitive impairment, anxiety disorder, and use of an antipsychotic medication. A physician’s order dated 10/9/25 discontinued Remeron 7.5 mg by mouth at bedtime, and review of the eMAR confirmed the medication was no longer being administered. During interview and record review, the IPN stated the care plan should have been revised to update the resident’s needed care. The DON stated care plans should be revised for changes in condition, changes in physician orders, or when a medication is discontinued, and that new medications should be incorporated into the active care plan. The facility policy stated care plans are revised as changes in the resident’s condition dictate and are reviewed at least quarterly.
Missing Documentation for Ordered Restorative Nursing Care
Penalty
Summary
The facility failed to ensure that Resident 8 received restorative nursing care and that the RNA documented the services provided five times a week as ordered. Resident 8 was admitted with diagnoses including COPD, gastrostomy, and contractures of the right and left ankles. The resident did not have capacity to understand and make decisions, was rarely or never understood, and was observed lying in bed, non-verbal, with contracted hands and legs. The physician's orders included bilateral upper extremity resting hand splints, bilateral upper extremity elbow extension splints, a left knee splint, gentle passive ROM to both upper extremities, and passive ROM to both lower extremities on weekdays as tolerated. During record review, the Restorative Administration Record from 12/29/2025 through 1/1/2026 did not show any documentation. RNA 1 stated the resident received ROM exercises and splints daily and that the documentation was in the electronic record, but RN 1 verified the documentation was missing and noted RNA 1 may not have been able to document electronically. The DON stated the resident was in the RNA program, needed restorative nursing care because the resident was bedbound and had contractures, and that if it was not charted, it was not done.
Room Size Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure 19 of 21 resident rooms met the required square footage of 80 square feet per resident in multiple resident rooms. The affected rooms were Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, 18, 19, 20, and 22. During review of the facility’s room waiver letter dated 1/2/2026, the facility stated there was ample room for wheelchairs, medical equipment, mobility, and movement of ambulatory residents in those rooms, and that there was adequate space for nursing care and that resident health and safety were not in jeopardy. The facility’s Client Accommodations Analysis dated 1/2/2026 listed the room dimensions and bed counts for the affected rooms, including several 2-bed rooms and some 4-bed rooms. During interview, the Assistant Administrator stated the facility was requesting a room waiver for the listed rooms and that nothing had changed since the last recertification survey, including bed occupancy. During observation from 12/30/2025 to 1/2/2026, surveyors noted the rooms had adequate space, nursing care, comfort, and privacy, with enough room for residents to move freely and for wheelchairs and walkers to be used. The DON also stated there was enough space for staff to provide care, and a resident interviewed stated there was enough room for personal belongings and that the room space was sufficient.
Failure to Develop Specific and Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop specific and resident-centered care plans for three sampled residents, resulting in care plans that did not adequately address the residents' individual needs. For one resident with hypertensive heart disease and generalized muscle weakness, the care plan only instructed staff to administer medication and diet as ordered, without specifying the medication name or providing detailed interventions. The Infection Preventionist Nurse (IPN) confirmed that the care plan lacked specificity and should have included the medication name. Another resident with a history of pneumonia, sepsis, and GERD had care plans that were not updated to reflect current conditions. The care plan for sepsis related to pneumonia remained active even though the resident was no longer receiving antibiotics or had active pneumonia. The IPN acknowledged that the care plan should have been discontinued after the last dose of antibiotics and that failure to update care plans could lead to medication errors and negatively affect resident care. The care plan for GERD also lacked specificity, as it did not list the medication by name. A third resident with dyspepsia and muscle weakness had a care plan that instructed staff to provide diet as ordered, administer medication as ordered, and frequently check for reassurance, but again did not specify the medication. The IPN and Director of Nursing (DON) both stated that care plans should be individualized, specific, and updated promptly to reflect changes in the resident's condition or treatment. The facility's policy required person-centered, comprehensive, and interdisciplinary care planning, but the reviewed care plans did not meet these standards.
Failure to Follow Physician Order for Medication Administration
Penalty
Summary
A licensed nurse failed to follow a physician's order for a resident with hypertensive heart disease and generalized muscle weakness by not checking and documenting the resident's heart rate prior to administering losartan, a medication for high blood pressure. The physician's order specifically required that losartan be held if the resident's heart rate was less than 60 beats per minute, and that the heart rate be checked daily before administration. Review of the Medication Administration Record (MAR) and Vital Summary showed that from 12/13/2025 to 12/22/2025, the resident received ten doses of losartan without any documentation of heart rate readings prior to administration on multiple days. Interviews with the Infection Preventionist Nurse (IPN) and Director of Nursing (DON) confirmed that the nurse did not carry out the physician's order as required. Facility policies reviewed indicated that care and services should be provided in accordance with physician orders, and that vital signs must be taken as ordered, especially when there are conditional parameters for medication administration. The failure to check and document the heart rate prior to administering losartan constituted a violation of professional standards of quality and facility policy.
Failure to Adhere to Advance Directive and POLST Policies
Penalty
Summary
The facility failed to adhere to its policy regarding advance directives and Physician Orders for Life-Sustaining Treatment (POLST) for three residents, leading to potential conflicts with their healthcare wishes. For Resident 43, the facility did not ensure that the Advance Healthcare Directive Acknowledgement form was filled out correctly, and the POLST was not signed by the legal representative upon admission. The resident, diagnosed with Alzheimer's disease and dementia, lacked the capacity to make decisions, and the inconsistency in documentation was noted but not corrected by the Social Services staff. The POLST was incorrectly signed by a caregiver from a previous facility, and the legal representative was not informed, leading to a discrepancy in the resident's resuscitation preferences. Resident 19's case involved a failure to complete an Advance Healthcare Directive upon admission. The resident, who had severe cognitive impairments due to conditions like dysphagia following a stroke and Parkinson's Disease, did not have a properly filled out Acknowledgement Form. The form lacked documentation on whether the resident's representative was provided with information about creating an advance directive, and it was not signed or dated by the representative. This oversight meant that the facility did not have clear documentation of the resident's or their family's healthcare wishes. For Resident 37, the facility did not ensure that the Advance Healthcare Directive Acknowledgement Form and the POLST were completed. The resident, who had moderately impaired cognition, was readmitted with conditions such as pneumonia and muscle weakness. The forms were missing critical information, including signatures and dates, which made them incomplete. The Director of Nursing acknowledged that these forms should have been completed to ensure the facility staff were aware of the resident's or legal representative's wishes, highlighting a significant lapse in following the facility's policies and procedures.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to adhere to its policy for posting accurate nurse staffing data in the lobby, a location accessible to residents and visitors. Specifically, the facility did not post accurate hours for Certified Nurse Assistants (CNAs) on multiple dates, including 10/15/2024, 10/16/2024, 10/17/2024, 10/18/2024, 10/19/2024, and 10/23/2024. The Director of Staff Development (DSD) acknowledged that the posted staffing numbers were incorrect, as the projected hours were posted instead of the actual hours worked. This discrepancy was noted during a review of the Staffing and Nursing Hours (SNH) and Nursing Staffing Assignment and Sign-in Sheet (NSASS) records. The Director of Nursing (DON) confirmed that the purpose of the SNH form is to provide accurate information about the hours staff provided direct care to residents. Additionally, on 10/23/2024, it was observed that there was no staffing information posted in the facility's lobby, which is a prominent location accessible to visitors. The DSD confirmed that the staffing information was only posted at the nursing station, not in the lobby as required by the facility's policy. The facility's policy mandates that nurse staffing data should be posted daily at the beginning of each shift in a prominent place accessible to residents and visitors, such as the lobby area. The failure to post accurate and accessible staffing information could potentially affect the quality of care provided to residents.
Failure to Ensure Appropriate Use of Psychotropic Drugs
Penalty
Summary
The facility failed to ensure that two residents on psychotherapeutic drugs were free from unnecessary medication. For one resident, the facility did not identify specific target symptoms for the use of Seroquel, which was prescribed for schizophrenia manifested by hearing voices and responding to internal stimuli. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that the target behavior was vague, making it difficult to monitor the effectiveness of the medication. Additionally, the facility did not attempt a gradual dose reduction (GDR) for Paroxetine HCL, despite the resident's minimal to no worsening of depression symptoms, as noted in the resident's records. Another resident had been on Zyprexa and Lexapro for schizophrenia and depression, respectively, without any documented evidence of a past failed attempt at GDR. The DON admitted that there was no specific target symptom identified for the use of Zyprexa, as the assumption was made that the resident was hearing voices due to talking to herself. The facility's policy requires that GDR be attempted at least twice a year, and the lack of specific target symptoms and GDR attempts could lead to inappropriate use of psychotropic drugs. The facility's policy and procedure for psychotropic and psychotherapeutic drugs require a written physician order specifying the duration and circumstances for medication use, including specific behavior manifestations. The failure to adhere to these policies and procedures resulted in the potential for inappropriate use of psychotropic drugs, affecting the residents' physical, emotional, and psychosocial well-being.
Sanitation Failure in Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage and distribution of ice, as evidenced by the presence of black and yellow substances in the internal components of a Manitowoc ice machine. Observations revealed these substances around the ice dicer and water outlet, which were not cleaned according to the manufacturer's recommendations. The Dietary Supervisor acknowledged the presence of these substances and admitted that the machine had not been cleaned as required, potentially leading to health hazards for residents. The ice from this contaminated machine was distributed to 40 residents before breakfast. Interviews with staff, including a Dietary Aide and Maintenance Worker, revealed a lack of proper cleaning procedures. The Dietary Aide was instructed to clean only the exterior of the ice machine, while the Maintenance Worker admitted to not following the manufacturer's cleaning guidelines, using bleach instead of the recommended cleaner and sanitizer. The cleaning logs were inaccurately signed off, indicating deep cleaning that did not occur. The Director of Nursing confirmed the risk of illness from the contaminated ice, highlighting the failure to maintain sanitary conditions as per the facility's policy and procedure on sanitation.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care that maintained or enhanced a resident's dignity and respect, specifically for one resident who was observed being fed by a CNA while the CNA was standing over them. This action was contrary to the facility's policy, which emphasized the importance of promoting resident dignity by having staff seated at eye level with residents during feeding. The resident in question had been readmitted to the facility with diagnoses including encephalopathy and muscle weakness, and was assessed as needing assistance with feeding due to severely impaired cognition. During the observation, the CNA was standing at the resident's right side while feeding them, which was confirmed by the CNA's own admission that she preferred to stand due to the bed's height. Interviews with the RN and DON revealed that the usual practice was for staff to stand while feeding residents, although the DON acknowledged that sitting at eye level was the preferred method to promote dignity. The facility's policy on resident dignity explicitly stated that staff should avoid standing over residents while assisting them to eat, highlighting a discrepancy between policy and practice.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident, identified as Resident 30, by not ensuring the call light was within reach and appropriate for the resident's physical ability. Resident 30 was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, affecting the right dominant side. The resident's care plan, revised in April 2024, indicated a risk for falls due to a history of cerebrovascular accident with right hemiplegia, and instructed nursing staff to provide the call light within reach and instruct the resident to use it. However, during an observation in October 2024, the call light was found hanging at the foot of the bed, out of the resident's reach. The resident's Minimum Data Set (MDS) from July 2024 indicated moderately impaired cognition and a need for maximum assistance with daily activities, including toileting hygiene and dressing. A Fall Risk Assessment from October 2024 assessed the resident as high risk for falls due to being chair-bound and needing assistance with elimination. During an interview, the Director of Nursing acknowledged that the call light was not within reach and emphasized the necessity for it to be accessible to ensure the resident could call for help if needed. The facility's policy, revised in 2018, also required call lights to be within easy reach of residents.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate Pre-Admission Screening and Resident Review (PASRR) Level II recommended specialized add-on services into the assessment, care planning, and transitions of care for Resident 38. This deficiency was identified during a review of Resident 38's records, which showed that the resident was readmitted with diagnoses of chronic obstructive pulmonary disease (COPD) and schizophrenia. The PASRR Level II report recommended mental health rehabilitation activities and psychotherapy/counseling as necessary specialized services to address the resident's mental health needs. During an interview and record review with the Director of Staff Development (DSD), it was revealed that the DSD was unaware that the PASRR Level II recommendations needed to be included in the resident's care plan. The facility's policy and procedures indicated that PASRR Level II evaluations should be incorporated into residents' assessments and care plans, but this was not done for Resident 38, placing the resident at risk of not receiving appropriate specialized care.
Failure to Create Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to create a care plan for a resident who experienced a 10% weight loss over three months. The resident, who was admitted with a diagnosis of major depressive disorder, had intact cognitive abilities and required assistance with eating. Despite the significant weight loss documented in the resident's records, no care plan was developed to address this issue. Interviews with facility staff, including a registered nurse and the director of nursing, revealed that they were unaware of the resident's weight loss and acknowledged that a care plan should have been created. The absence of a care plan meant that staff were not monitoring the resident's weight loss, which could potentially lead to further weight loss. The facility's policy indicated that care plans should be revised as changes in a resident's condition occur, but this was not done in this case.
Failure to Provide Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication board or other functional communication system for a non-English speaking resident, identified as Resident 24, who only speaks and understands Vietnamese. Resident 24 was readmitted to the facility with diagnoses including diabetes mellitus and dementia. The resident's care plan, dated the same day as the readmission, indicated that a communication device should be available to help the resident communicate daily needs. However, during an observation, it was noted that there was no communication board or system available in Vietnamese for Resident 24, and the facility had no Vietnamese-speaking staff. The Director of Staff Development (DSD) confirmed the absence of a communication device in Vietnamese after searching the resident's bedside table and drawer. The DSD acknowledged that such a device should always be available to prevent delays in care, especially in emergencies. The facility's policy and procedure documents indicated that communication boards should be provided for residents who do not speak or understand English, and a designated cellular phone with a translation application should be available. Despite these policies, the necessary communication tools were not provided, placing Resident 24 at risk for miscommunication and delayed care.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt appropriate alternative interventions before installing side rails for a resident, which could lead to the risk of entrapment and physical injuries. The resident, who was admitted with diagnoses including morbid obesity, schizophrenia, and major depressive disorder, requested bilateral one-half side rails due to a fear of falling and to aid in self-repositioning. The resident's cognitive abilities were intact, and they required substantial assistance with rolling. During an observation, the resident confirmed using the side rails to help turn in bed. Interviews with facility staff revealed that there was no documentation of alternative interventions being attempted before the installation of the side rails. A registered nurse mentioned that alternatives such as floor mats, roll guards, and concave mattresses could have been considered. A licensed vocational nurse noted that foam bolsters were attempted but removed due to the resident's anxiety, and no further alternatives were tried. The Director of Nursing acknowledged the need for staff to attempt more than one alternative and document these efforts before resorting to side rails. The facility's policy required an assessment and trial of alternative methods before implementing side rails.
Failure to Explain Medications to Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 23, during a medication pass. Licensed Vocational Nurse 1 (LVN 1) did not explain the medications and their purposes to Resident 23, which was against the facility's Policy and Procedure on Medication and Treatment Administration. This oversight resulted in Resident 23 being uninformed about the medications being administered, which included treatments for conditions such as schizophrenia, hyperlipidemia, Parkinson's Disease, and seizure disorders. Resident 23 was readmitted to the facility with diagnoses including Parkinson's Disease and muscle weakness and was cognitively intact according to the Minimum Data Set. During the medication pass, LVN 1 administered nine medications without naming or explaining them to Resident 23. The Director of Nursing confirmed that medications should be explained to residents to ensure they are aware of what they are taking and to prevent potential medication errors. The facility's policy also indicated that licensed nurses should explain medication use and side effects to residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the secure storage of medications in the medication cart at Station One, specifically for Resident 34. During a medication pass observation, a registered nurse (RN 1) was seen preparing medications for Resident 34 and walked away from the medication cart without locking it. This left the cart and the medications on top of it unattended. RN 1 admitted to leaving medications such as Actos, ASA, and Bupropion on top of the cart and acknowledged that the cart should have been locked to prevent unauthorized access by residents. Resident 34, who was admitted with diagnoses including major depressive disorder, attention and concentration deficit, and anxiety, had an order for several medications, including Actos, ASA, Bupropion, Docusate Sodium, and Prednisolone Acetate Ophthalmic Suspension. The Director of Nursing (DON) confirmed that licensed staff are required to lock the medication cart when unattended and dispose of dropped medications properly. The facility's policies also indicated that medication storage should prevent access by other residents, and medications removed from the cart should be transferred to a designated holding area.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to ensure that 18 out of 21 resident rooms met the required square footage of 80 square feet per resident in multiple resident rooms. This deficiency was identified through observation, interviews, and record reviews. The rooms in question were Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20, and 22. Despite the facility's request for a room waiver, which claimed that there was ample space for wheelchairs, medical equipment, and resident mobility, the rooms did not meet the regulatory requirements for space per resident. During the survey, it was observed that the rooms provided adequate space for nursing care, comfort, and privacy, and residents were able to move freely. Interviews with residents and staff indicated that there were no issues with space for mobility or care provision. However, the facility administrator acknowledged that the room sizes had not changed since the last recertification survey, and the number of beds remained the same, indicating a continued non-compliance with the square footage requirement.
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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 Baldwin Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra View Care Center | 0.2 mi | ★★★★★ | 13 | 0 |
| Victoria Care Center | 1.2 mi | ★★★★★ | 13 | 0 |
| West Covina Healthcare Center | 1.6 mi | ★★★★★ | 17 | 0 |
| Garden View Post Acute Rehabilitation | 1.6 mi | ★★★★★ | 20 | 0 |
| West Covina Medical Center D/p Snf | 1.9 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.