Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coastal View Healthcare Center during CMS and state inspections, most recent first.
Pureed Diet Food Texture Not Prepared Correctly: A HC prepared lunch trays, but a spoon test later found the pureed lasagna contained lumps and small particles while the pureed broccoli was smooth. The RD and DS confirmed the lasagna did not meet the facility’s puree standard, and the DS stated the HC used the wrong food processor. Six residents with physician-ordered puree diets had potential to receive an inappropriate food texture.
Missing Care Plan for Psychotropic Medication Monitoring: A resident with anxiety, migraine, chronic pain, HTN, DM, and hemiplegia had a BIMS of 00 and was prescribed Buspirone and Amitriptyline, but the chart did not contain an active care plan for the antidepressant use. MDS staff acknowledged the missing plan and stated the antidepressant needed a care plan for monitoring side effects, while MR staff verified no other active plan existed.
A resident with chronic pulmonary edema, dementia, and other diagnoses received oxygen without a documented physician order, and staff could not identify the ordered flow rate while the concentrator was running above the flowmeter maximum. In a separate event, an LPN took another resident’s BP over a thick sweater on the forearm, repeated the reading over the clothing, and the DON stated this was not standard practice.
Delayed Reordering of Nasal Spray A resident’s prescribed fluticasone propionate nasal spray was not reordered in time, and an LPN stated the resident would not receive the dose because a new bottle had to be ordered. The medication was found opened without an open date, and the pharmacy confirmed it was a 30-day supply that had only been filled twice despite expected monthly fills. The MAR showed several refused doses, and facility policy required meds to be reordered 5 days before needed.
Missing Monitoring for Antidepressant Use: A resident with anxiety disorder, migraine, chronic pain syndrome, HTN, DM, and hemiplegia after cerebral infarction had an antidepressant ordered for migraine and an antianxiety medication for anxiety. The record showed monitoring for the antianxiety medication but no documentation of monitoring for adverse effects or effectiveness of the antidepressant, and staff confirmed the missing documentation in the clinical record.
Failure to Use Beard Nets in Kitchen: Two male kitchen staff were observed handling tray carts and washing dishes without beard nets while in the kitchen. Both staff stated they only wear beard nets when preparing food, while the DS confirmed beard nets are required for male staff with facial hair whenever working in the kitchen. The facility policy stated that beards and mustaches must wear beard restraints.
A resident with a high fall risk and on anticoagulant therapy experienced three falls in one day. The facility did not complete required post-fall reassessments, failed to update the care plan after each fall, and did not notify the physician about the resident's use of blood thinners or the subsequent falls. The lack of communication and documentation was confirmed by staff interviews and record review, and the resident was later found unresponsive and pronounced deceased.
Nursing staff failed to obtain and document accurate vital signs for multiple residents as ordered for COVID-19 precautions, instead duplicating previous entries in the electronic MAR. Several nurses admitted to using a system function to copy prior vital signs due to workload, resulting in inaccurate records and noncompliance with physician orders.
The facility did not update care plans to include fall prevention recommendations made by the IDT after multiple residents experienced falls. Despite documented interventions such as keeping beds in the lowest position, using non-skid socks, and providing a clutter-free environment, these were not incorporated into the care plans. The DON confirmed that care plans were not revised as required by facility policy, and there was no documentation of updates or completion of post-fall assessments.
Staff failed to respond promptly to resident call lights, with some lights remaining unanswered for extended periods despite being visible and audible at the nursing station. A resident reported frequent delays of up to 30 minutes for assistance, and staff interviews confirmed inconsistent response practices. The DON stated that all staff are expected to answer call lights within five minutes, but observations showed this was not consistently followed.
A resident admitted with chronic respiratory failure, aphasia, and anxiety disorder did not have floor mats placed as required by their care plan and physician orders, increasing fall risk. Both the DON and an LN confirmed the absence of mats, contrary to facility policy on comprehensive care planning.
A resident with multiple health issues, including a rectal abscess and major depressive disorder, experienced unnecessary pain due to the facility's failure to follow prescribed pain management orders. Despite orders for Oxycodone for moderate to severe pain, Tylenol was administered instead, as confirmed by the MAR and staff interviews. The facility's Pain Management Protocol was not adhered to, resulting in inadequate pain management for the resident.
A resident with dementia consistently refused hygiene care, and the facility failed to report this to the doctor or responsible party. Despite the resident's cognitive impairment and refusal of care, there were no notifications or care plan revisions. Staff interviews revealed a lack of documentation and reporting systems for CNAs, and the DON acknowledged the failure to follow procedures for documenting changes in condition.
A resident with dementia and chronic kidney disease was observed with bilateral quarter side rails raised in bed without a physician's order, as required by facility policy. A review of the care plan and physician orders confirmed the absence of the necessary order, which was acknowledged by an LPN during an interview.
The facility did not meet the nutritional needs of 72 residents by failing to follow the recipe for meatball sub sandwiches, using insufficient ground beef and incorrect measurements of Italian dressing due to inadequate measuring utensils. This resulted in altered nutritional value of the meals served.
A facility failed to ensure a resident's advanced directive matched their POLST, leading to potential treatment inaccuracies. The advanced directive indicated a choice not to prolong life, while the POLST aimed to prolong life by all means. The discrepancy was noted by staff, but the facility did not update the documents to reflect the resident's current wishes.
A facility failed to review the risks and benefits of bed rails with a resident or their representative and did not obtain informed consent before installing bed rails. A resident was observed with side rails raised, and a nurse confirmed that informed consent was not obtained. The facility's policy required informed consent for the use of side rails, which was not followed, leading to a deficiency.
The facility failed to label and date a multidose vial of tuberculin PPD after it was opened. During an inspection, a licensed nurse found the vial in the medication refrigerator without a date label, contrary to facility policy. The product box indicated it should be discarded after 30 days.
The facility failed to ensure proper sanitary and food handling practices, as observed with a male employee working without a beard net, food being prepared in a kitchen sink, and an uncovered trash can being wheeled around the kitchen. The dietary supervisor acknowledged these issues, and the Registered Dietician confirmed the need for proper practices.
The facility failed to clean and disinfect a glucometer, as observed during an inspection of a medication cart. Two LNs confirmed the presence of red stains on the glucometer, which was stored dirty, contrary to the facility's policy requiring cleaning and disinfection between resident use. This oversight had the potential to spread disease among residents.
A facility failed to accurately assess a resident's wandering behavior and the use of a wander alarm. The MDS assessment incorrectly indicated no wandering behavior, despite documentation of an incident and the placement of a wander alarm. The MDS Coordinator acknowledged the errors, which could delay treatment.
Pureed Diet Food Texture Not Prepared Correctly
Penalty
Summary
The facility failed to ensure that a pureed lasagna was prepared in a smooth consistency free of lumps, as required for residents on physician-ordered puree diets. During a concurrent observation and interview in the kitchen, the head cook was observed preparing and arranging lunch trays and stated the meals were ready to be served. When the Registered Dietician and Dietary Supervisor later performed a spoon test of the pureed foods, the pureed broccoli was smooth and free of lumps, but the pureed lasagna contained lumps and small particles. The Registered Dietician directed the Dietary Supervisor to further blend the lasagna until a smooth consistency was achieved and acknowledged the concern regarding the puree texture. The Dietary Supervisor stated that the head cook did not use the correct food processor for the pureed diet and acknowledged the concern with the lasagna's consistency. The facility policy for Regular Puree Diet stated that pureed foods should be smooth and free of lumps, hold their shape, not be too firm or sticky, and should not weep. Six residents with physician-ordered puree diets, including Residents 105, 42, 53, 70, 104, and 91, had potential to receive an inappropriate food texture.
Missing Care Plan for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed and implemented for one resident with diagnoses including anxiety disorder, migraine, chronic pain syndrome, hypertension, diabetes, and hemiplegia following cerebral infarction. The resident’s MDS indicated a recent re-entry to the facility after a three-day hospitalization, and the BIMS score was 00, indicating significant cognitive issues. The resident was prescribed Buspirone for anxiety and Amitriptyline for migraine headache, but the clinical record showed no plan of care had been initiated and implemented for the resident’s antidepressant use since readmission. The record review also showed a document titled Psychotherapeutic Medications: Risk and Benefits that listed potential risks and side effects of antidepressants, including sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity, and excess weight gain, with special attention for heart disease, glaucoma, chronic constipation, seizure disorder, and edema. During interviews, Medical Records staff verified that current care plans were filed in the chart and that no other active plan of care existed elsewhere. MDS coordinators acknowledged the missing care plan and stated that the antidepressant prescribed for migraine headache should have had a care plan for monitoring side effects, but they were unable to provide documentation of a plan of care for the antidepressant use.
Oxygen Therapy Without Order and Blood Pressure Taken Over Clothing
Penalty
Summary
The facility failed to ensure oxygen therapy was provided in accordance with professional standards of practice for Resident 51, a female admitted with chronic pulmonary edema, hypertension, unspecified dementia, and a displaced fracture of the base of the neck of the right femur. The record review showed an SBAR dated 12/14/25 documenting desaturation and increased sleepiness, with a pulse oximetry reading of 87% on 4 LPM, but the SBAR did not specify how oxygen was being delivered. Surveyors found no physician order or documentation of physician notification or approval for oxygen use in the resident’s medical record. During observation on 12/15/25, the resident was seen lying in bed with an oxygen mask positioned on her forehead while the oxygen concentrator was running above the marked maximum level of the flowmeter tube at 5 LPM. RN5 could not state the exact oxygen flow rate the resident should have been receiving and later could not locate any physician orders for oxygen therapy prior to 12/15/25. The facility also failed to follow standard practice when taking a blood pressure reading for Resident 55. During observation, LN3 was seen taking the resident’s blood pressure on the left forearm with the cuff placed over a thick sweater. When the cuff popped open, LN3 stated she was going to get a bigger cuff, then took the blood pressure again in the same location and over the sweater. Resident 55 stated that blood pressure is taken with clothing at times and described the sweater as thick. The DON later stated that it is not acceptable to take a blood pressure reading over clothing and that it is not a standard of practice.
Delayed Reordering of Nasal Spray
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure timely reordering of Resident 48’s prescribed fluticasone propionate nasal spray. During observation and interview on 12/16/2025, a nurse stated the resident would not receive the nasal spray because a new bottle needed to be ordered from the pharmacy, and the medication was found opened without an open date, with the nurse confirming that medications are to be dated when first opened and wasted if the open date cannot be determined. Review of the MAR for September through December 2025 showed four refused doses in September and one refused dose in November, with the remaining days indicating the resident received the medication. The contracted pharmacy confirmed the medication was a 30-day supply with expected monthly fill dates but had only been filled on 8/23/25 and 12/16/25. Facility policy stated medications are to be reordered five days in advance of need to assure an adequate supply is on hand.
Missing Monitoring for Antidepressant Use
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met for one of 11 sampled residents. Resident 9 had diagnoses including anxiety disorder, migraine, chronic pain syndrome, hypertension, diabetes, and hemiplegia following cerebral infarction, and had a BIMS score of 00 indicating significant cognitive issues. The resident's OSR and MAR showed prescriptions for Buspirone for anxiety disorder and Amitriptyline for migraine headache, and the record showed monitoring for adverse effects of the antianxiety medication but not for the antidepressant medication. A review of Resident 9's clinical record from August through November 2025 found no documentation of monitoring for adverse side effects related to Amitriptyline. The facility's psychotherapeutic medication policy stated that staff should document monitoring for adverse complications, and staff interviews confirmed the missing documentation. The MDS Coordinators stated residents on psychotropic medication must be monitored for effectiveness and adverse effects, and the Administrator acknowledged that Resident 9 should have been monitored regardless of the indication for the psychotropic medication and confirmed the missing documentation.
Failure to Use Beard Nets in Kitchen
Penalty
Summary
The facility failed to ensure dietary staff followed sanitary food handling practices when male kitchen staff worked in the kitchen without beard nets covering their facial hair. During an observation on 12/15/25 at 8:50 a.m. in the kitchen, two male kitchen staff were seen handling tray carts and washing dishes without beard nets. In interviews later that morning, one kitchen staff member stated he does not use a beard net when working in the kitchen and only wears one when preparing food, and the other stated he does not use a beard net while in the kitchen unless he is preparing food. The Dietary Supervisor confirmed that male kitchen staff with facial hair are required to wear beard nets while working in the kitchen. Review of the facility's Dress Code policy dated 2023 stated that if applicable, beards and mustaches must wear beard restraints.
Failure to Complete Post-Fall Assessments and Notify Physician for High-Risk Resident on Anticoagulant
Penalty
Summary
The facility failed to provide a safe environment and appropriate care services for a resident with a high risk of falls and on anticoagulant therapy. The resident, an elderly male with a history of atrial fibrillation and generalized weakness, experienced three falls within a short period. Despite a documented high fall risk and care plan interventions requiring ambulation with assistance and careful handling due to anticoagulant use, the facility did not complete post-fall reassessments or update the care plan after each incident as required by policy. Additionally, the facility did not notify the resident's physician after the second and third falls, nor did they communicate the resident's use of heparin, a blood thinner, which increased the risk of bleeding complications. Interviews with nursing staff revealed a lack of communication regarding the resident's medication status and the absence of physician notification following multiple falls. The physician confirmed not being informed about the resident's anticoagulant use or the subsequent falls, which could have influenced clinical decisions. Record reviews showed no evidence of post-fall assessments or care plan revisions after each fall, and the Director of Nursing was unaware of the required post-fall assessment form referenced in facility policy. The facility's policies required significant information, such as changes in condition and fall incidents, to be reported to the attending physician and documented in the clinical record, which was not done in this case. The resident was later found unresponsive and pronounced deceased the morning after the falls.
Failure to Accurately Assess and Document Resident Vital Signs
Penalty
Summary
The facility failed to ensure that each resident received an accurate assessment reflective of their status at the time of assessment, as required by physician orders for COVID-19 prevention. Specifically, for all 10 sampled residents, vital signs were not monitored and recorded as prescribed. Instead, duplicate vital sign entries were documented across multiple shifts and dates, with identical values being recorded hours apart, which is not clinically plausible. This was observed in the Medication Administration Records (MARs) and confirmed through review of physician orders that required vital sign monitoring every shift or every four hours for COVID-19 precautions. Interviews with multiple licensed nurses revealed that the 'insert previous vitals' option in the electronic MAR system was used to duplicate vital sign entries, rather than obtaining and recording new measurements as ordered. Several nurses admitted to using this function due to high workload and time constraints, acknowledging that this resulted in inaccurate documentation. Some nurses recognized that this practice could be considered falsification of medical records and was not in compliance with physician orders. The Director of Nursing and other staff also acknowledged that it is not possible for vital signs to remain exactly the same over multiple hours, and that such duplication should not occur. The review of facility policy indicated that vital signs are to be taken and recorded according to the resident's condition and physician orders. Despite this, the MARs for all sampled residents showed repeated instances of duplicate entries, with some nurses stating they did not review previous vital signs before documenting, and others expressing discomfort or lack of recall regarding the practice. The deficiency was identified through record review and staff interviews, which confirmed that the required assessments were not performed as ordered, and inaccurate information was entered into the residents' medical records.
Failure to Update Care Plans with Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that care plans for three residents were revised to include fall prevention recommendations made by the Interdisciplinary Team (IDT) following multiple falls. For each resident, the IDT conducted meetings after fall incidents and documented specific recommendations such as keeping the bed in the lowest position, using non-skid socks, providing a clutter-free environment, using floor mats, and implementing bowel and bladder retraining programs. However, these recommendations were not incorporated into the residents' care plans, as confirmed by a review of the care plans and interviews with the Director of Nursing (DON). Resident 1 experienced multiple falls and had IDT recommendations documented after each incident, but these were not reflected in the care plans. Similarly, Resident 2 had several falls and repeated IDT meetings with recommendations, including additional interventions like bolster mattresses and x-rays, none of which were updated in the care plans. Resident 3 also had multiple falls, and the IDT's recommendations were not incorporated into the care plans. In each case, the DON acknowledged during interviews that the care plans had not been updated as required. The facility's policy and procedure on falls required that care plans be updated following a fall and that a post-fall assessment be completed, documenting that the care plan was revised to reflect new interventions. Despite this policy, there was no documentation that the care plans for these residents were updated after their falls, and the DON was unaware of the required post-fall assessment form referenced in the policy.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely responses to resident call lights, as required by its own policy and procedure, which states that call lights should be answered promptly. During observations, multiple call lights in resident rooms were illuminated and accompanied by a loud buzzing noise at the nursing station, with some remaining unanswered for extended periods. Staff interviews revealed that call lights are sometimes answered by non-nursing staff, such as a respiratory therapist, particularly when residents require suctioning. One resident reported that staff response to call lights typically takes about 30 minutes, indicating a persistent issue. Further observations showed a licensed nurse present at the nursing station while call lights continued to buzz, but the nurse did not respond, citing being occupied with an admission and the presence of three CNAs, none of whom were observed nearby. The Director of Nursing confirmed that the facility's expectation is for call lights to be answered within five minutes and that all staff are responsible for responding. These findings demonstrate a pattern of delayed responses to resident call lights, with staff either not present or not responding in a timely manner.
Failure to Implement Fall Care Plan Intervention
Penalty
Summary
The facility failed to implement a fall care plan intervention and follow physician orders for a resident, which had the potential to lead to negative outcomes in the event of a fall. The resident was admitted to the facility with diagnoses including chronic respiratory failure, aphasia, and anxiety disorder. During an observation and interview, it was noted that there were no floor mats on either side of the resident's bed, despite physician orders and the care plan indicating that floor mats should be present to mitigate fall risks. The Director of Nursing and a Licensed Nurse both confirmed that the resident's care plan and physician orders required floor mats to be placed on both sides of the bed. The facility's policy on comprehensive care planning emphasizes the need for a resident-centered care plan with measurable objectives and timeframes to meet each resident's needs. However, the absence of floor mats as per the care plan and physician orders indicates a failure to adhere to these guidelines, potentially compromising the resident's safety.
Failure to Follow Pain Management Orders
Penalty
Summary
The facility failed to ensure proper pain management for a resident, resulting in the resident experiencing unnecessary pain. The resident, who was admitted with a rectal abscess, a newly placed colostomy, general muscle weakness, difficulty walking, legal blindness, and major depressive disorder, reported that his pain medication took a long time to work and that his pain was not well managed. The physician's order specified that Oxycodone should be administered every four hours as needed for moderate to severe pain, but the Medication Administration Record (MAR) showed that Tylenol was given instead for pain levels that required Oxycodone, indicating a failure to follow the prescribed pain management orders. Interviews with facility staff, including a CNA and a licensed nurse, confirmed that the resident was receiving pain medication, but the Director of Nursing acknowledged that the pain medication orders were not followed as prescribed. The facility's Pain Management Protocol emphasized the importance of assessing pain, educating staff, and intervening before pain becomes severe, but these procedures were not adhered to in this case. The failure to follow the pain management orders led to the resident experiencing unnecessary pain, as confirmed by the review of the resident's care plan and medication records.
Failure to Report Resident's Refusal of Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident received necessary hygiene care when the resident consistently refused such care, and this refusal was not reported to the doctor or responsible party. The resident, who was admitted with dementia and other behavioral disturbances, had a Brief Interview for Mental Status (BIMS) score of 2, indicating significant cognitive impairment. Despite the availability of cue cards in English and Cantonese, the resident refused diaper changes and showers, as observed and corroborated by other residents with higher BIMS scores. The resident's care plan noted a risk for injury or decline due to non-compliance with care, but there were no notifications to the doctor or revisions to the care plan to address the ongoing refusals. Interviews with staff revealed that the Certified Nurse Aides (CNAs) reported the resident's refusals to Licensed Nurses (LNs), but there was no system for CNAs to document these refusals. The Director of Nursing (DON) confirmed that the process for documenting a change of condition and notifying the responsible party and doctor was not followed. The facility's policy required that any change in a resident's condition be promptly reported to the Nurse Supervisor/Charge Nurse, but this was not adhered to in the case of the resident's consistent refusal of care.
Failure to Obtain Physician Order for Side Rails
Penalty
Summary
The facility failed to obtain a physician order for the use of bilateral quarter side rails for one resident, identified as Resident 25. This deficiency was identified during a review of the resident's care plan and physician orders, which revealed that there was no documented physician order for the side rails, despite their use being observed. The facility's policy requires a comprehensive assessment, physician's order, informed consent, and a care plan for the use of any device attached to a bed. During an interview, a licensed nurse confirmed the absence of a physician's order for the side rails. Resident 25, who was admitted with diagnoses including dementia and chronic kidney disease, was observed in bed with the side rails raised, but without the necessary physician's order documented.
Failure to Follow Recipe Leads to Nutritional Deficiency
Penalty
Summary
The facility failed to meet the daily nutritional needs of 72 out of 92 residents by not adhering to the recipe card for meatball sub sandwiches. During an observation and interview, it was found that the cook used only 10 pounds of ground beef instead of the required 11 pounds and 4 ounces for the meatball recipe. The Dietary Supervisor confirmed that the facility only had 5-pound packages of ground beef, which led to the use of an insufficient amount of meat, altering the nutritional value of the meal provided to the residents. Additionally, the facility's kitchen staff demonstrated an inability to accurately measure ingredients, specifically Italian dressing, due to a lack of proper measuring utensils. The cooks used a 1-cup measuring utensil without calibration marks for smaller measurements, leading to incorrect estimations. The facility's policies and procedures emphasized the importance of following specific recipes to ensure residents receive a nourishing and well-balanced diet, which was not adhered to in this instance.
Discrepancy in Resident's Advanced Directive and POLST
Penalty
Summary
The facility failed to ensure that a current copy of an advanced directive was present in the medical record of one resident. During a review of the resident's medical record, it was found that the advanced health care directive, dated 2017, indicated a choice not to prolong life, while the POLST form, dated 2024, indicated a primary goal of prolonging life by all medically effective means. This discrepancy was acknowledged by a Licensed Nurse, who noted that the advanced directive and POLST should match. Further investigation with the Director of Nursing revealed that the resident had filled out the advanced directive upon admission, but it was not updated when the POLST was completed to reflect the resident's and family representative's wishes. The facility's policies on advanced directives and POLST forms require that any conflicts between these documents should be resolved by honoring the most recent expression of the resident's wishes. However, this procedure was not followed, leading to the potential for inaccurate treatment during an emergency medical situation.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rails with a resident or their representative and did not obtain informed consent prior to the installation of bed rails for one of the sampled residents. This deficiency was identified during a survey involving Resident 25, who was observed with bilateral quarter side rails raised in the middle section of the bed. The resident's care plan indicated that the resident and family were aware of the benefits and potential risks associated with the use of side rails, including entrapment, and that informed consent should be obtained for anything attached to a normal bed. During a concurrent record review and interview, a registered nurse confirmed that informed consent had not been obtained prior to the installation of the side rails for Resident 25. The facility's policy and procedure on informed consent, dated April 2017, required obtaining informed consent for the use of side rails as restraints, enablers, or assistive devices. The failure to adhere to this policy resulted in a deficiency related to the use of bed rails without informed consent.
Failure to Label and Date Opened Multidose Vial
Penalty
Summary
The facility failed to properly label and date a multidose vial of tuberculin purified protein derivative (PPD) after it was opened. During an observation and interview with a licensed nurse, it was found that the medication refrigerator in the west side medication storage room contained an open vial of PPD without a yellow sticker indicating the date it was opened. The licensed nurse acknowledged that the vial should have been labeled with the date it was opened. The product box specified that the opened product should be discarded after 30 days. A review of the facility's policy and procedure on preparation and general guidelines indicated that the date opened and the initials of the first person to use the vial should be recorded on multidose vials.
Improper Sanitary and Food Handling Practices
Penalty
Summary
The facility failed to maintain proper sanitary and food handling practices in the kitchen, as observed during a survey. A male employee, identified as Dietary 1, was seen working in the kitchen with facial hair but without a beard net on multiple occasions. The dietary supervisor acknowledged the absence of beard nets and mentioned that they were on order, but no temporary solution was implemented in the meantime. This lack of proper attire for kitchen staff with facial hair was confirmed by the Registered Dietician, who stated that beard nets should be worn. Additionally, improper food preparation practices were noted when Cook 1 was observed preparing meatballs using an ice cream scoop from a container of seasoned ground beef placed inside a kitchen sink. The dietary supervisor admitted that the sink area was used for food preparation when not in use, despite the Registered Dietician's assertion that food should not be prepared in the sink. Furthermore, Dietary 1 was seen pushing an uncovered trash can on wheels around the kitchen, collecting food scraps, which the dietary supervisor confirmed should have been covered.
Failure to Clean and Disinfect Glucometer
Penalty
Summary
The facility failed to properly clean and disinfect a glucometer, which is an instrument used to measure blood glucose levels. During an observation and interview with two licensed nurses, a medication cart was inspected, and a glucometer with red stains was found inside. Both nurses confirmed that the glucometer was stored dirty in the medication cart and acknowledged the need for it to be cleaned and disinfected. The facility's policy, dated January 2017, requires glucometers to be cleaned and disinfected between resident use, but this procedure was not followed, potentially leading to the spread of disease among residents.
Inaccurate MDS Assessment for Wandering and Alarm Use
Penalty
Summary
The facility failed to accurately assess and document the status of a resident's wandering behavior and the use of a wander alarm, as required by the Minimum Data Set (MDS) assessment tool. The resident's MDS assessment incorrectly indicated no wandering behavior, despite documentation and staff confirmation of an episode of wandering and an attempt to exit the facility. Additionally, a wander alarm was ordered and placed on the resident following this incident, but the MDS assessment inaccurately recorded the alarm as being used daily, rather than less than daily, during the 7-day look-back period. The inaccuracies in the MDS assessment were acknowledged by the MDS Coordinator, who is responsible for ensuring the accuracy of resident assessments before submission to the Centers for Medicare & Medicaid Services (CMS). The facility's policy and procedure for MDS assessments, as well as the coding instructions for wandering behavior and alarm use, were not followed correctly, leading to the discrepancies in the resident's documented status. These errors in assessment could potentially delay and affect the treatment of the resident.
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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 Ventura
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ventura Post Acute | 0.6 mi | ★★★★★ | 0 | 0 |
| Victoria Care Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Oxnard Manor Healthcare Center | 4.5 mi | ★★★★★ | 13 | 0 |
| Glenwood Care Center | 5.1 mi | ★★★★★ | 1 | 0 |
| Shoreline Care Center | 7.4 mi | ★★★★★ | 17 | 0 |
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