Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Costa Del Sol Healthcare during CMS and state inspections, most recent first.
Wound Care and Care Plan Deficiencies for a Resident With a Left Elbow Incision: A resident returned from an outside appointment with a left elbow incision, but the SBAR did not show that wound care and daily monitoring orders were obtained. The resident later said staff had not cleaned the wound and only wrapped it with gauze, and observation found the dressing loose, saturated, and covered with dried blood. The care plan for the status post left elbow incision did not include interventions for wound care, assessment, or follow-up, and the TXN and DON stated the missing wound-focused care plan placed the resident at risk for complications.
Failure to Obtain and Transcribe Wound Care Orders: A resident with a left elbow surgical incision after an I&D did not have documented wound care, daily assessment, or follow-up orders in place, and staff did not verify or clarify the orders after the resident returned from a post-procedure visit. The MAR/TAR did not show wound monitoring or treatment, the dressing was observed loose and saturated, and staff interviews confirmed that wound orders were not obtained, transcribed, or followed consistently.
Bedside Storage of Non-Self-Administered Medications: A resident with intact cognition and independence with ADLs had eye drops and a nasal spray left at the bedside even though the resident’s self-administration form showed the resident did not want to self-administer medications. An RN confirmed the meds should not have been left there and stated this could allow incorrect self-administration or another resident to obtain the medications.
Multiple residents with indwelling or suprapubic catheters were observed with visible white sediments and/or cloudy, amber urine in catheter tubing and drainage bags, while dependent on staff for ADLs and unable or unwilling to answer questions. Nursing staff acknowledged that catheters should be assessed at least daily or each shift for sediments, cloudiness, blood, and other changes, and that physicians should be notified when such changes occur, but also admitted that catheters had not been properly assessed, including not lifting drainage bags or tubing to inspect them. Physician orders and care plans for these residents required every-shift monitoring of urine character and prompt physician notification for potential UTI, and facility policy directed staff to report unusual urine appearance and signs of UTI immediately, yet these requirements were not followed, resulting in the identified deficiency.
A resident with ESRD on dialysis and heart failure, who was cognitively able to express needs, had a care plan and diet orders specifying a renal, controlled carbohydrate diet and documented food dislikes, including pasta. The care plan required staff to review the food preference sheet and provide alternative choices when the main entrée conflicted with preferences. During a meal observation, the resident was served penne pasta despite this documented dislike, and the Dietary Manager acknowledged the mismatch and noted that LVNs were responsible for verifying trays against lunch tickets, indicating the resident’s food preferences were not followed.
Failure to Reconcile Hospital Discharge Medications: A resident with lupus, PTSD, and HTN returned from a GACH with new discharge prescriptions for ibuprofen and Norco, but the medication list was not reconciled on return. The MAR showed the resident received different doses than those listed on the hospital discharge paperwork, and the RN and ADON stated the prescriptions were not obtained and reconciled before medications were administered.
Facility staff did not perform or document required daily quality-control testing for glucometers on two medication carts, as shown by blank quality control logs on multiple days. LVNs confirmed the devices were used to test several residents' blood glucose levels during these periods, despite the absence of documented quality control checks, in violation of facility policy.
A multi-dose insulin pen used for a resident with diabetes was not labeled with the date it was opened or its expiration date. Staff interviews and record reviews confirmed that the pen should have been labeled according to facility policy and manufacturer instructions, which require disposal after 28 days. The DON acknowledged that the policy was not followed, and staff could not determine when the pen was first used or when it should be discarded.
A resident was transferred or discharged without adequate assessment of their needs and preferences, and without proper preparation for a safe transition to the next care setting.
A resident dependent on dialysis missed a scheduled session due to transportation delays, and the dialysis center was unable to accommodate the late arrival. Although the session was rescheduled for the next day and the resident was monitored for complications, the physician was not notified of the missed treatment, contrary to facility policy. Staff interviews confirmed the oversight.
Three residents did not have complete, individualized care plans addressing their specific needs, including one resident's preference for a Cambodian-speaking interpreter and two residents' requirements for oxygen therapy. Staff were unaware of these needs due to missing or incomplete care plans, and facility leadership confirmed that care plans were necessary to guide safe and effective care.
Three residents with orders for oxygen therapy did not receive care consistent with their physician's orders, including incorrect oxygen flow rates, lack of monitoring and documentation of oxygen saturation, missing care plans, and absence of required 'Oxygen in Use' signage, as observed and confirmed by facility staff.
Licensed nursing staff failed to follow physician orders for holding medications on dialysis days, did not administer a newly prescribed antifungal medication in a timely manner, and did not accurately document controlled medication counts for several residents. These actions resulted in medication administration errors, delays in treatment, and discrepancies in medication records.
Two residents with ESRD and other chronic conditions received medications, including blood pressure drugs, on their scheduled dialysis days despite physician orders to hold these medications. Nursing staff did not clarify or follow the orders, and medication administration records confirmed the errors, which were acknowledged by the ADON, DON, and involved nurses.
A resident with severe cognitive impairment and no decision-making capacity received an increased dose of Seroquel after informed consent was obtained directly from the resident, rather than from a responsible party, contrary to facility policy and documented incapacity.
Two residents' needs and preferences were not accommodated when one was repeatedly left without access to a call light despite severe cognitive impairment and dependence on staff, and another, who preferred Cambodian and required an interpreter, was not provided with language assistance or communication aids. Staff communicated in English and did not use available tools or interpreters, contrary to facility policy.
A nurse failed to notify the physician or complete required assessments after a resident with severe cognitive impairment experienced multiple seizures and received Ativan on several occasions. The nurse only documented the medication administration and did not follow facility policy for change of condition notifications, preventing timely physician intervention.
Two residents received psychotropic medications without documented attempts at non-pharmacological interventions or clear behavioral indications. One resident with dementia and anxiety was given Ativan and Seroquel repeatedly, even when few or no behavioral episodes were recorded, and medication dosages were increased based on verbal reports rather than documented evidence. Another resident with anxiety and other conditions received clonazepam without specific behavioral monitoring, as orders and records lacked clear documentation of the behaviors being treated. Staff interviews confirmed these deficiencies in documentation and practice.
The facility did not ensure that MDS assessments accurately reflected the care and services provided to two residents. One resident receiving oxygen therapy and another receiving anticonvulsant and anti-anxiety medications were not properly documented in their respective MDS assessments, despite physician orders and medication records indicating these treatments.
A resident with severe cognitive impairment and a seizure history experienced a seizure, but staff did not obtain timely physician orders to monitor for further seizure activity as required by facility policy. This resulted in a lack of appropriate monitoring and documentation until orders were eventually put in place.
A resident with end stage renal disease and diabetes had IV lines in both arms that were not assessed or maintained according to physician orders and facility policy. The left arm IV and dressing were not changed for over a week, while the right arm IV dressing was dislodged, undated, and the tubing was bloodied. Staff failed to communicate and document the presence and condition of the right arm IV, resulting in the resident experiencing pain, discomfort, and increased risk of infection.
The facility failed to submit a written report of an abuse investigation within the required five working days. Two residents, both with cognitive impairments, were involved in a physical altercation. The incident was reported to local authorities on the same day, but the Director of Nursing admitted the investigation report was not sent to the state agency within the required timeframe, as per facility policy.
A resident with chronic pain conditions did not receive prescribed medications due to the facility's failure to ensure timely delivery from the pharmacy. The resident's muscle relaxant and pain injection medications were unavailable when needed, as the facility did not follow its policy to reorder medications in advance. Interviews with staff confirmed the oversight in medication management.
Two residents were discharged from an LTC facility without proper arrangements for home health services and necessary medical equipment. One resident, requiring extensive assistance with ADLs, was left confined to a wheelchair at home, leading to skin issues and hospitalization. Another resident, needing continuous oxygen therapy, was discharged without verified oxygen equipment or instructions, risking respiratory distress. The facility failed to follow its discharge planning policy, resulting in significant health risks.
A resident with severe cognitive impairment and multiple health issues was found with a large bruise on the left breast and rib cage. The facility failed to report this injury of unknown origin to the CDPH within the required 24-hour period, as per their policy. This delay was confirmed through staff interviews and a review of the facility's procedures.
The facility failed to ensure call lights were within reach for three residents, impacting their ability to call for assistance. Observations revealed call lights were out of reach for residents with muscle weakness and Parkinson's Disease, who required assistance with ADLs. Staff interviews confirmed the importance of accessible call lights, aligning with facility policy.
The facility failed to administer timely gastrostomy tube (GT) feedings for two residents as per physician's orders. Observations showed that one resident's GT feeding was turned off and another's was disconnected, despite orders for continuous feeding. Both residents had diagnoses including adult failure to thrive and diabetes, and were dependent on assistance for daily activities. The facility's policy required adherence to physician's orders for enteral nutrition, which was not followed in these instances.
The facility failed to maintain effective infection control by storing cleaned and uncleaned oxygen concentrators together without proper labeling. Staff interviews revealed confusion and miscommunication about the cleaning and storage process, with some staff unaware of the designated storage areas for clean equipment. The Infection Preventionist confirmed that uncleaned concentrators were mistakenly stored with clean ones, contrary to facility policy, leading to potential cross-contamination risks.
A resident in respiratory distress did not receive proper ventilation due to incorrect use of an Ambu-bag, as staff failed to achieve a full seal. Additionally, the emergency cart was not checked daily and lacked a non-rebreather mask, contrary to facility policies. The DON admitted that the absence of necessary supplies could delay emergency treatment.
The facility failed to provide adequate nursing staff, resulting in insufficient Restorative Nursing Assistant (RNA) services for residents requiring range of motion exercises and splint application. A resident with limited mobility did not receive prescribed RNA services, while another resident was unable to get out of bed daily due to staff being too busy. The staffing shortage led to deficiencies in care and psychosocial distress for residents.
The facility failed to accurately assess ROM limitations for five residents, leading to discrepancies between evaluations and MDS assessments. Residents with conditions like hemiplegia, Parkinson's disease, and contractures had their mobility limitations inaccurately documented, potentially affecting their care. Observations confirmed limited mobility, and the MDS Coordinator acknowledged the inaccuracies.
The facility failed to provide prescribed ROM and mobility services to five residents, leading to potential decline in their physical condition. Observations and interviews revealed that residents did not receive necessary exercises and splint applications as ordered, due to staffing shortages.
A resident at high risk for falls was observed ambulating without staff assistance in a room where a pool of enteral nutrition had spilled on the floor, creating a slipping hazard. The facility's policy requires floors to be clean and free of spills to prevent accidents, but this was not adhered to, as confirmed by a nurse and the DON.
A facility failed to provide necessary respiratory care for three residents, leading to potential health risks. One resident with COPD did not receive required respiratory equipment and treatments, another received high-flow oxygen without a humidifier, and a third was given oxygen therapy without a physician's order. These deficiencies highlight lapses in following medical protocols and facility policies.
The facility failed to ensure safe food storage and preparation practices, with unlabeled nutritional supplements and expired food items found in storage. Staff did not follow proper hygiene practices, such as handwashing and glove changing, increasing the risk of cross-contamination and foodborne illness. These deficiencies were observed during a survey, highlighting lapses in food safety and sanitation protocols.
The facility failed to accurately document RNA services for two residents with limited mobility. One resident's records did not indicate the application of knee splints, while another's lacked documentation of PROM exercises. Despite physician orders and therapy recommendations, these tasks were not properly recorded in the electronic system, leading to incomplete records.
The facility failed to maintain infection control measures, including the use of PPE for a resident on enhanced barrier precautions and proper cleaning of assistive devices. A nurse did not wear required PPE while handling a gastrostomy tube, and a nursing aide neglected to clean a gait belt and walker after use. Additionally, cloth gait belts were improperly cleaned with bleach wipes, which are ineffective on porous surfaces.
A resident with mobility impairments due to a stroke was not assisted by staff to get out of bed and sit in his wheelchair daily, as per his preference. Despite the facility's policy to accommodate residents' needs, staff cited high patient assignments as a reason for not providing the necessary assistance, resulting in the resident getting out of bed only twice a week.
A resident with anxiety disorder, schizophrenia, and depression was admitted to the facility with an inaccurate PASRR Level I screening, which failed to identify her serious mental disorders. The facility's Admission Coordinator and DON did not catch this discrepancy, resulting in the resident not being referred for a necessary Level II evaluation, as required by the facility's policy.
A resident with multiple health conditions did not receive her morning medications on time due to the nursing staff's failure to follow the physician's orders. The resident, who was supposed to receive medications for hypertension, depression, and COPD, reported feeling dizzy when she woke up. The LVN responsible admitted to not administering the medications as scheduled, citing the resident's sleep as the reason. This oversight was recognized by the DON as a risk for serious health complications.
Two residents in the facility were found with long and dirty fingernails, indicating a failure in providing adequate fingernail care and maintaining personal hygiene. One resident required maximum assistance for personal hygiene, while the other required moderate assistance. Staff, including a CNA, LVN, RN, and the DON, acknowledged the responsibility of CNAs to clean and trim residents' fingernails daily, as per facility policy.
A resident with a gastrostomy tube was not receiving enteral nutrition as ordered, as the tube was closed and nutrition was spilling onto the floor. The resident had conditions requiring tube feeding, and the failure to administer nutrition correctly was confirmed by an LVN. The DON highlighted the importance of proper nutrition administration to prevent decline in the resident's condition.
Licensed nurses failed to follow IV therapy protocols for a resident, including not labeling and dating the PIV site, not changing the dressing when compromised, and not removing the PIV after treatment completion. The resident, with multiple diagnoses and lacking decision-making capacity, was found with a soiled and dislocated PIV dressing, leading to potential harm.
Two residents experienced delays in pain management at a facility. One resident, with chronic pain, waited 36 minutes for pain medication after requesting it. Another resident, with neuropathy, missed a scheduled dose of Gabapentin and had no medication for breakthrough pain. Staff interviews confirmed that pain management protocols were not followed, leading to potential discomfort.
The facility failed to maintain sanitary conditions in the dumpster area, with one dumpster overfilled and uncovered, and trash littering the ground. This was observed during an interview with maintenance staff, who acknowledged the need for proper disposal to prevent pest attraction. Facility policies and FDA guidelines require dumpsters to be covered and free of litter.
The facility did not follow its policy on explaining binding arbitration agreements to residents and their responsible parties, leading to three residents signing agreements without understanding their implications. The Admissions Coordinator failed to document verbal acknowledgments of understanding, despite being trained on the policy.
Two residents in a LTC facility, both with conditions requiring assistance for ADLs, were found with long and dirty fingernails, indicating a failure in providing adequate fingernail care and maintaining personal hygiene. Staff acknowledged the issue and the associated risks, confirming that CNAs were responsible for daily cleaning and trimming of residents' fingernails.
Wound Care and Care Plan Deficiencies for a Resident With a Left Elbow Incision
Penalty
Summary
Proper wound management and care planning were not ensured for Resident 1, who was admitted and later readmitted to the facility with diagnoses including pneumonia, muscle weakness, and sepsis. Resident 1’s MDS dated 4/27/2026 indicated intact cognitive skills for daily decision making and independence with ADLs. The H&P dated 1/22/2026 stated Resident 1 could make needs known and make medical decisions. On 4/23/2026, an SBAR note documented that Resident 1 returned from a medical appointment with an incision to the left elbow mass, but the SBAR did not indicate that orders for wound care and daily wound monitoring were obtained. During an interview on 5/20/2026, Resident 1 stated she had surgery on her left elbow the previous month and was worried the surgical wound would become infected because staff had not cleaned it, and that nursing staff only wrapped the dressing with gauze. During observation the same day, the left elbow wound dressing was loose, saturated with a brown substance, and had dried blood; the wound had one incision and sutures. Review of the care plan titled, At Risk For Pain, Infection Due To Status Post Left Elbow Incision, initiated 4/23/2026, showed it did not include interventions for the care, assessment, and follow up of the left elbow wound. The TXN stated the lack of a Weekly Skin IDT and the lack of wound-related care plan interventions placed Resident 1 at risk for complications related to the wound, like dehiscence and infection. The DON stated appropriate wound care plan interventions were important to support wound healing and prevent infection, and that the lack of a care plan placed Resident 1 at risk for delayed treatment, wound healing, and infection.
Failure to Obtain and Transcribe Wound Care Orders
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided for one resident with a left elbow surgical incision after an incision and drainage procedure. The resident was admitted and readmitted with diagnoses including pneumonia, muscle weakness, and sepsis. Her MDS indicated intact cognitive skills for daily decision making and independence with ADLs, and her H&P stated she could make needs known and make medical decisions. After the resident returned from a medical appointment with the left elbow incision, the change of condition note did not indicate that wound care orders or daily wound monitoring orders were obtained. The resident’s physician orders from 4/23/2026 through 5/19/2026 did not include daily wound care or assessment for the left elbow wound, and the MAR and TAR did not show the wound was assessed, monitored for infection, or treated. The resident told staff she was worried the wound would become infected because staff had not cleaned it and had only wrapped it with gauze. When observed, the dressing was loose, saturated with a brown substance, and had dried blood, and the wound had one incision with sutures. Staff interviews and record review showed the wound care process was not clarified or accurately carried out. RN 1 stated there were no wound care or assessment orders obtained and no documentation that nurses attempted to clarify or obtain orders after the procedure. LVN 2 stated the notes did not indicate treatment, assessment, or follow-up orders and that the admitting nurse or treatment nurse should have obtained them. TXN 2 stated he reinforced the dressing with rolled gauze without verifying wound care orders, and TXN 3 stated she obtained wound care orders but did not remember to transcribe them. A skin evaluation later listed cleansing and dressing orders, but RN 1 stated there were no transcribed orders after that assessment.
Bedside Storage of Non-Self-Administered Medications
Penalty
Summary
The facility failed to ensure medications were not stored at the bedside for one resident. Resident 1 was admitted and readmitted to the facility with diagnoses including pneumonia, muscle weakness, and sepsis. The resident’s MDS indicated intact cognitive skills for daily decision making and independence with ADLs, and the H&P stated the resident could make needs known and make medical decisions. Physician orders dated 5/1/2026 included Artificial Tears Solution 1.4% to be instilled in both eyes four times daily and Flonase Allergy Relief Suspension to be given as one spray in both nostrils twice daily. During a concurrent observation and interview on 5/20/2026 at 10:28 a.m., one bottle of Artificial Tears Solution and one bottle of Flonase Allergy Relief Suspension were observed on the resident’s bedside. The resident stated the licensed nurses left the medications at the bedside. During a concurrent interview and record review, RN 1 reviewed the resident’s Self-Administration of Medication Observation Form, which indicated the resident did not want to self-administer medications. RN 1 stated the medications should not have been left at the bedside because the resident was not to self-administer them, and that leaving them there created the possibility of incorrect self-administration or another resident obtaining the medications. The facility’s policy stated medications found at the bedside that are not authorized for self-administration are to be turned over to the nurse in charge for return to the family or responsible party.
Failure to Assess and Report Abnormal Urine Characteristics in Residents With Indwelling Catheters
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with indwelling urinary catheters and suprapubic catheters were maintained free of visible sediments and cloudiness in the urine, and that changes in urine character were assessed and acted upon as ordered. For one resident with a suprapubic catheter who was dependent in activities of daily living and had neuromuscular bladder dysfunction and urogenital implants, surveyors observed visible white sediments in the catheter tubing while the resident was in bed and unable to answer questions. This resident’s physician orders required staff to monitor changes in urine character every shift, including cloudiness, sediments, foul smell, blood, or concentrated urine, and to notify the physician for potential UTI. The resident’s care plan for bladder complications related to neurogenic bladder and suprapubic catheter also directed staff to notify the physician for signs and symptoms of UTI such as foul-smelling urine, color changes, hematuria, and sediments. Another resident with a Foley catheter, quadriplegia, genitourinary prosthetic devices, anoxic brain damage, and severe cognitive impairment was observed lying in bed with visible white sediments in the catheter tubing and amber-colored urine with sediments. During a concurrent interview, an LVN acknowledged the presence of sediments, stated that nurses must notify the physician when sediment builds up in the urine or tubing, and admitted the catheter had not been assessed that morning for sediments while wound care was performed. This resident also had physician orders to monitor urine character every shift for cloudiness, sediments, foul smell, blood, or concentrated urine and to notify the doctor for potential UTI, and a care plan indicating the need to notify the physician for signs and symptoms of UTI including foul-smelling urine, color changes, hematuria, and sediments. A third resident with a suprapubic catheter, paraplegia, neuromuscular bladder dysfunction, unspecified dementia, and dependence in ADLs was observed in bed with cloudy urine in the drainage bag and tubing. During the observation, an LVN identified the cloudiness and stated that suprapubic catheters should be assessed daily for signs and symptoms of infection such as blood, cloudiness, and sediments, and that allowing urine to remain cloudy or with sediments was not acceptable. This resident’s physician orders also required every-shift monitoring of urine character for cloudiness, sediments, foul smell, blood, or concentrated urine and physician notification for potential UTI, and the care plan for an indwelling Foley catheter and neurogenic bladder specified that the resident should show no signs or symptoms of UTI and that the physician should be notified for foul-smelling urine, color changes, hematuria, and sediments. A fourth resident with a Foley catheter, benign prostatic hyperplasia, neuromuscular bladder dysfunction, unspecified dementia, and severe cognitive impairment was observed in bed with sediments present in the Foley catheter drainage bag and tubing. During the concurrent interview, an LVN stated that they usually assess Foley catheters before starting the shift and again during medication pass but admitted they had not picked up the drainage bag or tubing to properly assess it and therefore had not seen the sediments. The LVN stated they should have picked up the drainage bag and checked it. This resident’s physician orders also required every-shift monitoring of urine character for cloudiness, sediments, foul smell, blood, or concentrated urine and physician notification for potential UTI, and the care plan for an indwelling Foley catheter and neurogenic bladder included interventions to notify the physician for signs and symptoms of UTI such as foul-smelling urine, color changes, hematuria, and sediments. In interviews, an LVN stated it was important to properly assess catheters every morning for changes in urine such as no output, sediments, cloudiness, or leaking, and that nurses need to inform the doctor and document a change of condition if there were any changes in the resident. The DON stated that it was the nurse’s responsibility to assess catheters every shift for urine appearance, including sediments, hematuria, or any characteristics that may indicate abnormalities, and that nurses are required to call the doctor and follow physician orders. The facility’s catheter care policy directed staff to observe residents for complications associated with urinary catheters and to report unusual findings, including unusual urine appearance, to the physician or supervisor immediately, as well as signs and symptoms of urinary tract infection or urinary retention. Despite these orders, care plan directives, and policy requirements, surveyors observed multiple residents with indwelling or suprapubic catheters who had visible sediments and/or cloudy urine without evidence that staff had adequately assessed and reported these changes as required.
Failure to Honor Documented Food Preferences for a Dialysis Resident
Penalty
Summary
The facility failed to provide meals that accommodated a resident’s documented food preferences. The resident, who had end stage renal disease, dependence on renal dialysis, and heart failure, was cognitively able to express needs and understand others, and required only supervision or partial assistance with activities of daily living. The resident’s care plan, dated 3/15/2026, documented a goal that the resident would receive meals aligned with food preferences daily and would verbalize satisfaction most weeks. Interventions directed staff to review the resident’s food preference sheet upon admission, update it as needed, and ensure alternative meal choices were provided if the main entrée conflicted with the resident’s preferences. On review of the resident’s diet orders, the resident was to receive a renal 80 g protein, constant carbohydrate diet with regular texture. The resident’s lunch ticket for 03/16/2026 listed specific dislikes, including pasta. During a concurrent dining observation, record review, and interview on 03/16/2026, the resident’s lunch plate was observed to contain penne pasta despite the documented dislike. The Dietary Manager confirmed that the resident disliked pasta and might not eat the food served, and stated that LVNs were responsible for comparing lunch tickets with lunch trays to ensure residents received the correct diet and preferences. The facility’s policy on Resident Food Preferences required that preferences be assessed upon admission, communicated to the IDT, and documented in the care plan, but the observed meal did not reflect the resident’s documented preference to avoid pasta.
Failure to Reconcile Hospital Discharge Medications
Penalty
Summary
The facility failed to reconcile the medication list for a resident when she returned to the facility from a GACH on 11/18/2025. The resident had diagnoses including lupus, PTSD, and hypertension, and her MDS indicated she had no cognitive impairment and could make her needs known. She had been transferred to the GACH on 11/17/2025 after reporting back pain radiating to the left side, dizziness, nausea, and an elevated blood pressure of 223/137 mmHg. The GACH discharge medication reconciliation order report and prescription form listed Ibuprofen 600 mg by mouth every 6 to 8 hours as needed for pain or fever and Norco 5/325 mg by mouth every 6 hours as needed for pain. When the resident returned to the facility, the nurses' notes did not indicate that medication reconciliation was completed. The MAR showed that on 11/18/2025 and 11/20/2025 the resident received Ibuprofen 800 mg as needed for moderate pain, and on multiple shifts from 11/18/2025 through 11/20/2025 she received Norco 10-325 mg as needed for severe pain. The ADON stated she was unaware the resident returned with new prescriptions until the resident handed them to her on 11/20/2025, and RN 1 stated he forgot to ask the resident about the discharge papers and should have obtained and reconciled the prescriptions before administering medication. The DON stated that on readmission or transfer back from the GACH, the licensed nurse should obtain the discharge records and reconcile prescriptions with the primary care physician before administering medications.
Failure to Perform and Document Daily Glucometer Quality Control Testing
Penalty
Summary
The facility failed to ensure that daily quality-control testing was performed and documented for glucometers located in Medication Carts 1 and 3, as required by the facility's policy and procedure on Blood Glucose Monitoring and Quality Control. Record reviews revealed that the quality control logs for these glucometers were left blank on multiple days throughout the month, indicating that the required daily testing was not completed. Interviews with LVNs confirmed that the glucometers were used to test the blood glucose levels of several residents during the periods when quality control testing was not documented. The LVNs acknowledged their responsibility for performing and documenting daily quality control tests and stated that these tests are necessary to ensure the accuracy of blood glucose readings. Further review of the facility's policy and job descriptions confirmed that LVNs are responsible for maintaining equipment and documenting quality control testing daily. The Director of Nursing also confirmed that the facility's policy was not followed when daily quality control records were missing. The deficiency was identified through interviews and record reviews, which established that the lack of daily quality control testing and documentation could have affected the accuracy of blood glucose measurements for residents tested with these glucometers.
Failure to Label Multi-Dose Insulin Pen with Open and Expiration Dates
Penalty
Summary
A multi-dose insulin pen used for a resident with diabetes was found to be unlabeled with the date it was opened and its expiration date. The resident, who had a history of diabetes mellitus and fluctuating capacity to make medical decisions, was admitted to the facility and had an order for Insulin Glargine. During an observation, a nurse confirmed that the insulin pen in use for this resident was not labeled as required. Multiple staff interviews confirmed that the pen should have been labeled with both the open and expiration dates, in accordance with facility policy and the manufacturer's instructions, which specify that the pen should not be used more than 28 days after opening. Further review of the facility's policy and the insulin manufacturer's guidelines confirmed the requirement for labeling multi-dose vials and pens with the date opened and expiration date. The Director of Nursing acknowledged that the facility's policy was not followed in this instance. The lack of labeling meant that staff could not determine when the insulin pen was first used or when it should be discarded, as confirmed by interviews with nursing staff and the pharmacist.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Notify Physician After Missed Dialysis Session
Penalty
Summary
The facility failed to notify a resident's physician when the resident missed a scheduled dialysis session. The resident, who had diagnoses including end stage renal disease, dependence on dialysis, and other significant medical conditions, was scheduled to receive dialysis three times a week. On the day of the missed session, transportation for the resident was delayed, resulting in the dialysis center being unable to accommodate the resident due to the late arrival. Although the dialysis session was rescheduled for the following day, the physician was not informed of the missed treatment. Documentation showed that the resident was being monitored for signs and symptoms of fluid overload after missing the dialysis session. Interviews with staff, including an LVN and the DON, confirmed that the physician was not notified of the missed session, despite facility policy requiring prompt notification of changes in a resident's condition or status. The staff acknowledged that the physician should have been informed to allow for potential additional orders or interventions.
Failure to Develop and Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement complete, resident-centered care plans for three residents, resulting in staff being unaware of critical care needs and preferences. For one resident with severe cognitive impairment and a preference for communicating in Cambodian, the care plan did not include the need for an interpreter, despite documentation in the Minimum Data Set (MDS) and confirmation from the resident’s emergency contact that he preferred communication in Cambodian. Staff routinely communicated with the resident in English, and there was no evidence that an interpreter was used, leading to potential misunderstandings and frustration for the resident. Two other residents, both with physician orders for oxygen administration, did not have care plans addressing their oxygen therapy. One resident with chronic obstructive pulmonary disease (COPD) and diabetes mellitus was receiving oxygen at two liters per minute via nasal cannula, but no care plan was found outlining the administration, monitoring, or goals for oxygen therapy. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that a care plan was necessary to guide staff in providing safe and effective oxygen therapy, including details such as flow rate, oxygen saturation goals, and potential side effects. Similarly, another resident with heart failure and peripheral vascular disease had an order for oxygen therapy but lacked a corresponding care plan. The DON acknowledged that the absence of a care plan meant staff did not have guidance on the rationale for oxygen use, monitoring requirements, or interventions to ensure safe administration. Facility policy required that care plans be developed from comprehensive assessments, but these were not completed for the residents in question, resulting in staff being uninformed about essential aspects of their care.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with the residents' plans of care for three residents with orders for oxygen therapy. For one resident with COPD and diabetes, there was no assessment or documentation of oxygen saturation for a period of several days, despite physician orders to titrate oxygen based on saturation levels. Observations revealed that this resident was receiving four liters of oxygen per minute, contrary to the physician's order of two liters, and there was no 'Oxygen in Use' sign outside the room. The resident also did not have a care plan addressing oxygen administration, and the ADON confirmed that monitoring and documentation of oxygen saturation were not performed as required. Another resident with heart failure and peripheral vascular disease was observed receiving varying amounts of oxygen (one liter and 2.5 liters per minute) instead of the prescribed two liters per minute. There was also no 'Oxygen in Use' sign outside this resident's room, and the resident did not have a care plan for oxygen administration. The DON acknowledged the absence of a care plan and stated that such a plan was necessary to guide staff in providing safe and effective oxygen therapy. A third resident with COPD and sequelae of cerebral infarction was observed receiving more than the prescribed amount of oxygen (three liters and 2.5 liters per minute instead of two liters per minute) and also lacked an 'Oxygen in Use' sign outside the room. Although this resident had a care plan for oxygen therapy, the prescribed oxygen flow was not followed. Staff interviews confirmed the importance of adhering to physician orders for oxygen therapy and the need for appropriate signage to prevent fire hazards, as outlined in the facility's policy and procedure for oxygen administration.
Failure to Follow Physician Orders and Accurately Document Medication Administration
Penalty
Summary
Licensed nursing staff failed to follow physician orders regarding medication administration for multiple residents. For one resident with end stage renal disease on dialysis, blood pressure medications were administered on scheduled dialysis days despite an order to hold medications on those days. The nurse misinterpreted the order, believing it only applied when the resident was out of the facility, and did not clarify the order with the nurse practitioner. Both the nurse practitioner and the Director of Nursing confirmed that the order should have been clarified and that blood pressure medications should have been held prior to dialysis. Another resident with a fungal infection did not receive a newly prescribed dose of fluconazole in a timely manner. The assigned nurse failed to obtain the medication from the emergency kit when it was not delivered by the pharmacy, resulting in a two-day delay in treatment. Additionally, the antibiotic medication count sheet for this resident was inaccurate, as the nurse documented preparation of the medication but did not actually administer it, leaving all doses intact in the medication supply. For two other residents receiving pregabalin, the medication count sheets were not accurately maintained. In both cases, the number of doses documented on the count sheets did not match the actual number of doses remaining in the medication bubble packs. The nurses involved admitted to forgetting to document the preparation or administration of the medication, which resulted in discrepancies in the controlled medication records. The Director of Nursing acknowledged that such inaccuracies could lead to medication errors or undetected controlled medication discrepancies.
Failure to Hold Medications on Dialysis Days Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that two residents undergoing hemodialysis were free from significant medication errors by not holding medications as ordered by their physicians on scheduled dialysis days. For one resident with end stage renal disease (ESRD) and diabetes mellitus, the physician's order specified to hold medications on dialysis days. However, the Medication Administration Record (MAR) showed that the resident received multiple medications, including furosemide, on dialysis days. The Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN) confirmed that the order was not followed, and the nurses did not clarify which medications should be held, resulting in all medications being administered contrary to the order. Another resident with ESRD, chronic obstructive pulmonary disease (COPD), and diabetes mellitus also experienced a similar deficiency. The care plan indicated that blood pressure medications should be held on dialysis days as ordered by the physician. Despite this, the resident reported receiving blood pressure medications prior to dialysis appointments, and review of the electronic Medication Administration Record (eMAR) confirmed administration of these medications on multiple dialysis days. The LVN responsible for medication administration admitted to not checking the physician's orders before giving the medications. Interviews with nursing staff and the Director of Nursing (DON) further confirmed that the physician's orders were not followed for both residents. The facility's policy required medications to be administered as prescribed, but this was not adhered to, resulting in significant medication errors for residents with complex medical needs during their dialysis treatment.
Failure to Obtain Valid Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain proper informed consent for a psychotropic medication for one resident. The resident, who had diagnoses of dementia and anxiety disorder, was assessed as having severe cognitive impairment and was documented as lacking the capacity to understand and make decisions. Despite this, when the resident's Seroquel dosage was increased from 50 mg to 100 mg twice daily, the informed consent for the new dosage was obtained directly from the resident, rather than from a resident representative or responsible party as required by facility policy and the resident's documented incapacity. Interviews with facility staff, including the nurse practitioner and assistant director of nursing, confirmed that informed consent should be obtained from the resident or their representative prior to administering psychotropic medications, especially when there is a dosage change. The facility's policy also required that the prescribing clinician obtain informed consent from the appropriate party before administration. The failure to follow these procedures resulted in the administration of a higher dose of Seroquel without valid informed consent, as the resident was not capable of providing it.
Failure to Accommodate Resident Needs and Preferences for Call Light Access and Language Interpretation
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents by not ensuring a call light was within reach for one resident and by not providing appropriate language interpretation for another. In the first instance, a resident with severe cognitive impairment, dementia, anxiety disorder, and a history of falls was observed on multiple occasions with his call light placed out of reach, despite being dependent on staff for activities of daily living and repositioning. The resident stated he could not reach the call light, and staff confirmed that the call light should be accessible to allow the resident to request assistance. Facility policy required staff to ensure the call light was within easy reach, but this was not followed. In the second instance, a resident with Parkinson's disease, hemiplegia, generalized muscle weakness, and depression, who preferred to communicate in Cambodian and required an interpreter, was not provided with language assistance. Staff communicated with the resident in English, assuming he understood because he could say a few words, and did not use a communication board or interpreter. Observations showed the resident did not respond to staff communication in English, and staff relied on facial expressions to interpret his needs. The resident's emergency contact confirmed his preference for Cambodian, and facility policy required the use of interpreters or visual aids for residents with communication barriers, which was not implemented. Interviews with staff and review of facility policies confirmed that the call light should be within reach and that residents have the right to be informed and participate in their care planning in their preferred language. The failure to follow these policies resulted in the residents being unable to request assistance or understand the care being provided to them.
Failure to Notify Physician of Recurrent Seizure Activity
Penalty
Summary
Licensed Vocational Nurse (LVN) 3 failed to notify the physician when a resident with a history of seizures experienced multiple seizure episodes on six separate occasions. The resident, who had severe cognitive impairment and required substantial assistance for mobility, was prescribed Ativan as needed for seizures. The Medication Administration Records (MAR) indicated that Ativan was administered on each of these occasions for seizure activity. However, aside from documenting the administration of Ativan on the MAR, LVN 3 did not document the seizure activity elsewhere in the resident's medical record, did not notify the physician, and did not complete Change of Condition (COC) assessments as required by facility policy. During interviews, LVN 3 confirmed that she followed the medication administration orders but did not inform the physician or complete the necessary assessments after each seizure event. The Assistant Director of Nursing (ADON) stated that a COC assessment should be completed for each seizure and that physician notification is necessary, especially if seizures occur despite medication. The facility's policy requires physician notification for changes in a resident's medical or mental condition. This failure to notify the physician prevented timely adjustments to the resident's plan of care.
Failure to Document and Attempt Non-Pharmacological Interventions Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and that behavioral indications were present and documented prior to administering psychotropic medications for two residents. For one resident with dementia and anxiety disorder, records showed that medications such as Ativan and Seroquel were administered without prior documentation of non-pharmacological interventions or consistent behavioral indications. The resident's Medication Administration Records (MARs) indicated frequent administration of these medications even when there were few or no documented episodes of the behaviors they were intended to treat. Interviews with nursing staff and the Assistant Director of Nursing (ADON) confirmed that non-pharmacological interventions were not documented or attempted prior to medication administration, and that increases in medication dosage were based on verbal reports rather than verified behavioral documentation. For another resident with anxiety, depression, insomnia, and paraplegia, clonazepam was administered three times daily for anxiety manifested by "multiple concerns." However, the MARs and order summaries lacked specific documentation of the behavioral manifestations being monitored. Staff interviews revealed that the orders did not specify exact behaviors, and the lack of specificity in documentation and monitoring placed the resident at risk for prolonged and potentially unnecessary use of psychotropic medication. The Director of Nursing (DON) acknowledged that the absence of clear behavioral indications and monitoring could lead to inappropriate care planning and medication use. The facility's own policy required that psychotropic medications only be used when necessary to treat specifically diagnosed conditions, with clear documentation of symptoms and attempted non-pharmacological interventions. Despite this, the records and staff interviews demonstrated that these steps were not consistently followed for the two residents, resulting in the administration and escalation of psychotropic medications without adequate justification or documentation.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents accurately reflected the care and services they received. For one resident with a diagnosis of congestive heart failure, physician orders indicated the use of oxygen therapy as needed for shortness of breath, and the resident was observed receiving oxygen therapy at the bedside. However, the MDS assessment did not document the use of oxygen therapy. The MDS nurse confirmed that the physician order and observation supported the use of oxygen, but this was not reflected in the MDS. For another resident with a history of seizures and severe cognitive impairment, physician orders and the Medication Administration Record (MAR) showed the resident was receiving anticonvulsant and anti-anxiety medications. Despite this, the MDS assessment did not indicate the use of these medications. The MDS nurse acknowledged that the MDS failed to document the resident's use of anti-anxiety and anticonvulsant medications, which was inconsistent with the resident's medical records and medication administration history. The facility's policy required that MDS assessments consistently reflect information from progress notes, care plans, and resident observations.
Failure to Initiate Timely Seizure Monitoring Orders After First Seizure
Penalty
Summary
The facility failed to ensure that a resident with a history of seizures had appropriate physician orders to monitor for seizure activity following the resident's first documented seizure. The resident, who had severe cognitive impairment and required substantial assistance for mobility, experienced a seizure lasting three minutes. Despite this event, there were no orders in place to monitor for further seizure activity until a later date, leaving a gap in monitoring and documentation. Record review and staff interviews confirmed that nursing staff did not contact the physician for seizure monitoring orders immediately after the initial seizure episode. The facility's own policy required staff to monitor and document seizure activity for individuals with new seizures or seizure disorders, but this protocol was not followed in a timely manner for the resident in question.
Failure to Follow IV Line Care Policy and Physician Orders
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy and physician's orders regarding intravenous (IV) line care for a resident with end stage renal disease and diabetes mellitus. The resident had IV lines in both arms, with orders to check the IV line every shift and to change the IV line, dressing, and cap every three days. Observations over several days revealed that the left arm IV and its dressing had not been changed for at least nine days, and the right arm IV dressing was dislodged, undated, and the tubing was bloodied. The resident reported pain and discomfort from the IV, stated that the IV and dressing had never been changed, and was unaware of the reason for the continued presence of the right arm IV, which was not being used for medication administration. Record reviews and staff interviews confirmed that the required assessments and dressing changes were not performed as ordered. The Assistant Director of Nursing (ADON) acknowledged that she did not know the date the IV dressing was labeled, did not change the IV line or dressing as required, and did not inform the physician about the failure to change them. The ADON was also unaware of the right arm IV's continued presence and condition, which had not been assessed or maintained. The Treatment Nurse (TN) documented the presence of both IVs but did not communicate the right arm IV to the ADON, and the Director of Nursing (DON) confirmed that the right arm IV was not monitored, increasing the risk of infection. The facility's policy required IV site care and dressing changes at established intervals or immediately if the dressing was compromised, with assessments at least every eight hours. Despite these requirements, the resident's IV sites were not properly assessed or maintained, and communication failures among staff led to the right arm IV being overlooked for an extended period. The lack of adherence to policy and physician orders resulted in the resident experiencing pain, discomfort, and increased risk of infection.
Failure to Timely Report Abuse Investigation Findings
Penalty
Summary
The facility failed to provide a written report of the findings of an investigation into an allegation of abuse within five working days, as required by their policy. This deficiency involved two residents who were involved in a physical altercation. Resident 1, who has dementia, anxiety, dysphagia, and muscle weakness, was dependent on staff for activities of daily living and had moderately impaired cognitive skills. Resident 2, with altered mental status, diabetes mellitus, and a history of seizures, required supervision for daily activities and had severely impaired cognitive skills. On the day of the incident, Resident 1 was lying in bed and talking loudly, which irritated Resident 2. Despite being asked to lower his voice, Resident 1 continued talking loudly, leading Resident 2 to become agitated and hit Resident 1 on the face. This incident was reported to the Los Angeles County Department of Public Health on the same day via fax using the SOC 341 form, as required under the Welfare and Institutions Code. However, the Director of Nursing admitted that the five-day investigation report was completed but not faxed to the California Department of Public Health within the required timeframe. The facility's policy, revised in September 2022, mandates that reports of resident abuse be submitted to local and federal agencies within five working days of the reported allegations. This failure to comply with the reporting timeline had the potential to delay the State Survey Agency's investigation and placed the residents at risk for elder abuse.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that a resident's prescribed medications were readily available, leading to a deficiency in pharmaceutical services. The resident, who was admitted with conditions including osteoarthritis, neuropathy, and chronic pain syndrome, had a physician's order for Metaxalone, a muscle relaxant, to be administered as needed. However, the medication was not available when the resident requested it, as the pharmacy had not delivered the refill. Additionally, the resident had a physician's order for Kenalog injections to manage shoulder pain, but these medications were also not available when the physician attempted to administer them. Interviews with the resident and staff revealed that the refill for Metaxalone was sent to the pharmacy but had not been delivered, and the Kenalog order was not reflected in the facility's system. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledged the importance of timely medication delivery and the need for follow-up with the pharmacy. The facility's policy required medications to be reordered at least three days before the last dose to ensure availability, but this procedure was not followed, resulting in the resident experiencing discomfort and potential pain due to the unavailability of prescribed medications.
Failure in Safe Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure a safe discharge for two residents, leading to significant health risks and complications. Resident 1, who required extensive assistance with activities of daily living (ADLs) and mobility, was discharged without confirmed arrangements for home health services. Despite physician orders for home health services, the referral was delayed, resulting in Resident 1 being confined to her wheelchair at home, unable to perform basic hygiene tasks, and developing skin issues due to prolonged exposure to moisture. Interviews with the resident and a family friend revealed that Resident 1 was left without the necessary support, leading to emergency hospitalization for severe leg pain and a venous stasis rash. Resident 2, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and required continuous oxygen therapy, was discharged without ensuring the availability of necessary oxygen equipment and instructions. The facility did not verify the functionality of Resident 2's portable oxygen delivery device or provide education on the required oxygen therapy. This oversight placed Resident 2 at risk for respiratory distress and other complications associated with inadequate oxygen therapy. Interviews with a family friend and facility staff confirmed that the necessary checks and education were not conducted prior to discharge. The facility's policy and procedure for discharge planning were not followed, as evidenced by the lack of confirmed arrangements for follow-up care and services for both residents. The Social Services Director and other staff members acknowledged the deficiencies in the discharge process, highlighting the importance of ensuring that residents have the necessary support and equipment before leaving the facility. The failure to adhere to these protocols resulted in significant health risks for both residents, underscoring the need for thorough discharge planning and coordination with home health agencies.
Failure to Report Resident Injury in a Timely Manner
Penalty
Summary
The facility failed to report an unusual occurrence involving a resident to the California Department of Public Health (CDPH). The resident, who was admitted with diagnoses including adult failure to thrive, unspecified protein-calorie malnutrition, and type 2 diabetes, was found with a large bruise on the left side of the breast and rib cage. The resident's cognitive skills were severely impaired, requiring substantial assistance with activities of daily living. Despite the bruise being noticed on 9/5/2024, it was not reported to the CDPH within the required 24-hour timeframe, as per the facility's policy. The incident was discussed in an interdisciplinary team meeting on 9/6/2024, where it was noted that the resident complained of pain when care was provided to the affected area. The facility's policy on reporting injuries of unknown origin mandates immediate reporting to the administrator and state officials within 24 hours. However, this protocol was not followed, resulting in a delay in the investigation by CDPH. Interviews with staff, including the Restorative Nursing Assistant and the Director of Nursing, confirmed that the injury was not reported as required, highlighting a lapse in adherence to the facility's policies and procedures.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three of eight sampled residents, potentially impacting their ability to have their needs met promptly. During observations, Resident 2's call light was found hanging on the wall, out of reach, until a CNA provided it to the resident. Resident 2 had a history of muscle weakness and required supervision for activities of daily living (ADLs). Similarly, Resident 5's call light was stuck on the bed rail, out of reach, and the resident was unaware of its location. Resident 5 was dependent on assistance for ADLs and had no mental capacity to make medical decisions. Resident 6's call light was also out of reach, hanging on the bed rail, and the resident was dependent on assistance for ADLs due to Parkinson's Disease. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that call lights should always be within easy reach of residents to ensure their needs are met promptly. The facility's policy, dated 2010, also indicated that call lights should be within easy reach when residents are in bed or confined to a chair. The failure to adhere to this policy could result in residents being unable to call for assistance, potentially impacting their physical, mental, and psychosocial well-being.
Failure to Administer Timely GT Feedings
Penalty
Summary
The facility failed to ensure timely administration of gastrostomy tube (GT) feedings for two residents, Resident 3 and Resident 4, as per physician's orders. Observations revealed that Resident 3's GT feeding was turned off when it should have been on, according to the physician's order, which specified that the feeding should start at 2:00 p.m. and continue for 20 hours. Similarly, Resident 4's GT was found disconnected, despite the physician's order indicating that the feeding should also start at 2:00 p.m. and continue for 20 hours. Licensed Vocational Nurse 1 confirmed these discrepancies during interviews, acknowledging that the feedings were not administered as ordered. Resident 3 was admitted with diagnoses including adult failure to thrive, diabetes, and gastrostomy status, and was noted to have intact cognitive skills but was dependent on assistance for activities of daily living. Resident 4, also diagnosed with adult failure to thrive and diabetes, had the mental capacity to make medical decisions and was similarly dependent on assistance for daily activities. The facility's policy on enteral nutrition emphasized the importance of providing adequate nutritional support as ordered, which was not adhered to in these cases, potentially compromising the residents' nutritional needs.
Improper Storage of Oxygen Concentrators
Penalty
Summary
The facility failed to ensure effective infection control measures by improperly storing oxygen concentrators. Cleaned and uncleaned oxygen concentrators were stored together in the same room, Storage 1, without any labeling to distinguish between them. This practice was observed during an inspection, where it was noted that the concentrators were placed in various directions, some touching each other, and only one was covered in plastic. Licensed Vocational Nurse (LVN) 1 admitted that the room was too small to separate the clean from the unclean concentrators and that there was no labeling system in place. Interviews with staff revealed a lack of clarity and communication regarding the cleaning and storage process of the concentrators. The Director of Maintenance (DOM) stated that housekeeping was responsible for cleaning the concentrators every Monday, but there was no written policy to support this. Housekeeper 1 initially claimed all concentrators in Storage 1 were clean but later admitted that only the one covered in plastic was clean. LVN 2, who also served as a respiratory therapist, was unaware of the existence of Storage 2, where clean concentrators were supposed to be kept, and mistakenly believed that Storage 1 was for clean concentrators. The Infection Preventionist (IP) Nurse confirmed that clean concentrators should be stored in Storage 1 after being disinfected at the bedside, but uncleaned concentrators were mistakenly placed there. The facility's policy and procedure documents outlined the proper cleaning and storage protocols, but these were not being followed, leading to potential cross-contamination and infection risks. The DOM acknowledged the need for a separate room to store clean and dirty equipment and admitted that the current process could result in contamination of all equipment in Storage 1.
Deficient Emergency Response and Equipment Management
Penalty
Summary
The facility failed to correctly use a valve-bag-mask (Ambu-bag) for a resident in respiratory distress and did not ensure the emergency cart was adequately stocked and checked daily. A resident, who was admitted with respiratory failure and shortness of breath, was observed in respiratory distress with an oxygen saturation of 60% while on 3 liters per minute of oxygen. The respiratory therapist attempted to use an Ambu-bag but failed to achieve a full seal, which is necessary for effective ventilation, as the resident was moving and sitting up. The registered nurse confirmed that a proper seal is crucial to prevent oxygen from escaping and to provide effective ventilation. Additionally, the emergency cart lacked a non-rebreather mask, and there was no checklist to ensure the cart was checked daily, as per the facility's policies and procedures. The director of nursing acknowledged that staff should have checked the emergency cart daily and that the absence of necessary supplies could lead to delays in treatment during emergencies. The facility's policy required licensed nurses or designated staff to ensure the emergency cart was complete and stocked with essential items, including non-rebreather masks.
Inadequate Staffing Leads to Deficient Care and Resident Distress
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents requiring Restorative Nursing Assistant (RNA) services. Observations and interviews revealed that the facility had only one RNA staff available due to another RNA being on leave, which resulted in inadequate provision of range of motion (ROM) exercises, splint application, and ambulation for 43 residents. This included specific deficiencies in care for residents with limited mobility, such as Resident 8, who did not receive the prescribed RNA services for applying a left elbow extension splint five times per week. Further investigation showed that Resident 27, who had diagnoses including Parkinson's disease and contractures, did not receive passive range of motion (PROM) exercises to both arms and legs as ordered by the physician. Similarly, Resident 49, who was on palliative care, did not receive the required PROM exercises due to the staffing shortage. Interviews with the Director of Rehabilitation and the Director of Staff Development confirmed that the lack of adequate staffing was the reason for these deficiencies. Additionally, the facility failed to accommodate the preferences of Resident 61, who wished to get out of bed daily to sit in a wheelchair. Despite having the capacity to understand and make decisions, Resident 61 was unable to participate in his preferred activities due to staff being too busy to assist him. This led to psychosocial distress for the resident, as he was only able to get out of bed twice a week on average. The Director of Nursing acknowledged that staff should assist residents with such requests and that it was inappropriate for staff to claim they were too busy to help.
Inaccurate ROM Assessments in Residents
Penalty
Summary
The facility failed to accurately assess the range of motion (ROM) limitations for five residents, which could potentially affect the provision of care. Resident 8 was admitted with diagnoses including hemiplegia, dementia, and contractures. Despite assessments indicating severe and moderate ROM impairments in various joints, the Minimum Data Set (MDS) inaccurately reflected these limitations. Observations confirmed the resident's limited mobility, and the MDS Coordinator acknowledged the inaccuracies in the assessments. Resident 27, diagnosed with Parkinson's disease and contractures, also had discrepancies between the Rehab - Joint Mobility Screen (JMS), Occupational Therapy (OT), and Physical Therapy (PT) evaluations, and the MDS assessments. The MDS failed to document the ROM impairments noted in the evaluations, and observations showed the resident's limited mobility. The MDS Coordinator confirmed the inaccuracies, emphasizing the importance of accurate assessments for ensuring appropriate care. Similar issues were found with Residents 49, 61, and 63, where the MDS assessments did not accurately reflect the ROM limitations documented in other evaluations. These inaccuracies were confirmed through interviews and record reviews with the MDS Coordinator, who reiterated the necessity of accurate MDS assessments to monitor residents' conditions and ensure they receive the necessary care.
Failure to Provide Prescribed ROM and Mobility Services
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) and mobility for five residents with limited mobility. Resident 8 did not receive the prescribed application of a left elbow extension splint five times per week as ordered by the physician. Observations revealed that the splint was not applied on several occasions, and the resident reported pain when the splint was used. The Director of Staff Development (DSD) confirmed that the splint was not applied as required due to staffing issues. Resident 61 did not receive the prescribed passive range of motion (PROM) and active assistive range of motion (AAROM) exercises to the right leg and both arms, respectively. The resident reported that exercises were not performed regularly, and observations confirmed the lack of consistent exercise provision. The DSD acknowledged the failure to provide the required exercises, attributing it to insufficient staffing. Residents 27, 49, and 65 also did not receive the prescribed PROM exercises for their arms and legs. Observations and interviews indicated that these residents rarely received the necessary exercises, and the RNA Task Schedules were often left blank. The DSD and Director of Rehabilitation (DOR) confirmed the lack of services, again citing staffing shortages as the reason for the deficiency.
Hazardous Environment Due to Spilled Enteral Nutrition
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment for a resident, identified as Resident 75, who was at high risk for falls due to generalized weakness, gait/balance problems, and impaired mobility. The resident was admitted on January 15, 2024, and had intact cognitive skills for daily decision-making, requiring only set-up or clean-up assistance with ambulation. Despite these needs, the resident was observed ambulating in his room without staff assistance, where a pool of enteral nutrition was present on the floor, creating a slipping hazard. The pool of enteral nutrition originated from the bedside of Resident 75's roommate and extended into Resident 75's side of the room, accumulating under his bed. During an observation and interview, a Licensed Vocational Nurse acknowledged the slipping hazard posed by the liquid on the floor, which could lead to a fall for Resident 75. The Director of Nursing confirmed that floors and walkways should be clean and free of spills to prevent slips and falls, as per the facility's policy on safety and supervision of residents.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for three residents, leading to potential health risks. Resident 13, diagnosed with COPD, hypertension, dementia, and depression, was not provided with essential respiratory equipment such as a nebulizer, incentive spirometer, and oxygen supplies as per physician orders. Observations over two days confirmed the absence of these supplies in the resident's room, and interviews with nursing staff revealed a lack of clarity on who was responsible for administering the treatments. The Medication Administration Record showed no documentation of the required treatments being administered, placing the resident at risk for respiratory distress and exacerbation of COPD. Resident 57, admitted with acute respiratory failure and pneumonia, was receiving oxygen at 4.5 liters per minute without a humidifier, contrary to the facility's policy. The absence of a humidifier when administering oxygen at this level could lead to discomfort and nosebleeds due to dry nasal mucous membranes. Interviews with the Respiratory Therapist and the Director of Nursing confirmed the necessity of a humidifier in such cases, highlighting a failure in adhering to the facility's oxygen administration policy. Resident 69, with diagnoses including shortness of breath and heart failure, was receiving oxygen therapy without a physician's order. Observations confirmed the administration of oxygen via nasal cannula, and interviews with nursing staff and the Director of Nursing emphasized the requirement for a physician's order for oxygen therapy. This oversight in obtaining the necessary order for oxygen administration represents a significant lapse in following medical protocols, potentially compromising the resident's care.
Deficiencies in Food Storage, Labeling, and Staff Hygiene
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, which were observed during a survey. Nutritional supplements labeled to be stored frozen and used within 14 days of thawing were not monitored for their thaw date, leading to the potential risk of expired supplements being consumed by 24 residents on nutritional supplements. Four boxes containing 50 individual cartons of strawberry-flavored nutrition supplements were found in the walk-in refrigerator without a thaw date. The Dietary Aide confirmed that the supplements were delivered frozen and should have a thaw date to monitor their expiration. Additionally, the facility did not properly label and date food items in storage, leading to the potential consumption of expired food. A plastic bag of breaded food items was found in the walk-in freezer without a label or date, and previously opened ham and diced stew meat were stored beyond their recommended storage periods, covered in ice crystals and freezer burn. The Dietary Supervisor acknowledged that the freezer was overcrowded, and old items were not rotated, which contributed to the issue. Furthermore, a container holding dry food products was found dirty with food debris, indicating a lack of proper sanitation in the kitchen. The facility also failed to maintain proper hygiene practices among staff, which could lead to cross-contamination and foodborne illness. One staff member in the dishwashing area did not wash their hands before handling clean dishes, and another cook did not change gloves or wash hands before handling ready-to-eat food. These practices were observed during lunch service, where a staff member was seen performing multiple tasks without changing gloves or washing hands, increasing the risk of contamination. The facility's policies and procedures emphasized the importance of handwashing and proper glove use, but these were not followed, as observed during the survey.
Documentation Errors in RNA Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide accurate documentation for two residents with limited mobility and range of motion. Resident 8's clinical records did not indicate the application of both knee splints from November 2023 to February 2024, despite physician orders and physical therapy recommendations for such interventions. The RNA Task Schedule failed to include the application of knee splints as a separate task, leading to documentation errors. The Director of Rehabilitation and Director of Staff Development acknowledged these errors during a review of the records. Resident 63's clinical records also lacked documentation of passive range of motion (PROM) exercises to both legs from December 2023 to February 2024. Although physician orders and physical therapy discharge summaries recommended PROM exercises five times per week, the RNA Task Schedule did not reflect this task. The RNA Weekly Summary indicated that PROM was provided, but the task was not created in the electronic documentation system, resulting in incomplete records. The facility's policy and procedure on documentation require nursing personnel to maintain complete and accurate records. However, the documentation for both residents was found to be deficient, as it did not accurately reflect the RNA services provided. The discrepancies were identified during interviews and record reviews with the Director of Rehabilitation and Director of Staff Development, who confirmed the documentation errors.
Infection Control Deficiencies in PPE and Equipment Cleaning
Penalty
Summary
The facility failed to maintain proper infection control measures for Resident 27, who was on enhanced barrier precautions (EBP) due to the presence of a gastrostomy tube. Despite signage indicating the need for EBP and the availability of personal protective equipment (PPE) outside the resident's room, a Licensed Vocational Nurse (LVN) entered the room without donning the required gown and gloves. The LVN proceeded to handle the resident's gastrostomy tube without the necessary protective gear, acknowledging the oversight during an interview. The Infection Preventionist Nurse (IPN) confirmed that EBP was crucial for preventing the spread of multidrug-resistant organisms (MDROs) and that the failure to implement these precautions increased the risk of infection spread within the facility. In another instance, the facility did not adhere to infection control protocols concerning the cleaning of assistive devices used by Resident 69. After assisting the resident with ambulation using a vinyl gait belt and a front-wheeled walker (FWW), the Restorative Nursing Aide (RNA) failed to clean these items with bleach sanitizing wipes as required. The RNA admitted to neglecting this step due to the resident's eagerness to return to their room. The IPN reiterated the importance of disinfecting reusable equipment between uses to prevent cross-contamination among residents. Additionally, the facility did not follow proper cleaning procedures for cloth gait belts used by multiple Certified Nursing Assistants (CNAs). Observations revealed that CNAs wore cloth gait belts throughout the day, and some attempted to clean them with bleach sanitizing wipes, which are ineffective on porous surfaces like cloth. The IPN confirmed that the manufacturer's recommendations for the wipes specified use on non-porous surfaces only, and that cloth gait belts should be washed instead. The improper cleaning of these gait belts posed a risk of contamination, as they were used on multiple residents without adequate disinfection.
Failure to Accommodate Resident's Preference for Daily Wheelchair Use
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident, identified as Resident 61, who expressed a desire to get out of bed and sit in his wheelchair at least once a day. Despite having the capacity to understand and make decisions, Resident 61, who had impairments due to a stroke, required substantial assistance from staff to transfer from bed to wheelchair. Observations and interviews revealed that Resident 61 was often left in bed watching TV and was not assisted to get out of bed as per his preference. The resident reported that when he requested assistance, the CNAs informed him they were too busy due to high patient assignments, resulting in him getting out of bed only twice a week on average. Interviews with the Activity Director and the Director of Nursing confirmed that there were no restrictions on residents using the patio and that staff should assist residents in transferring to wheelchairs and supervise them as needed. The facility's policy indicated that residents' individual needs and preferences should be accommodated unless it endangered health and safety. However, the staff's failure to assist Resident 61, citing workload as a reason, was not in line with the facility's policy, leading to the deficiency.
Inaccurate PASRR Screening Leads to Deficiency
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for a resident, leading to a deficiency. The resident, who was admitted with diagnoses of anxiety disorder, schizophrenia, and depression, had a PASRR Level I screening that incorrectly indicated the absence of a serious mental disorder. This discrepancy was not identified during the facility's review process, which involved the Admission Coordinator and the Director of Nursing. As a result, the resident was not referred for a Level II evaluation by the state-designated mental health authorities, which is necessary to determine the need for specialized services. The facility's policy requires that all new admissions be screened for mental disorders through the PASRR process, and if a potential mental disorder is identified, a Level II evaluation should be conducted. However, in this case, the facility did not adhere to its policy, as the PASRR Level I screening was not accurately completed, and the necessary follow-up actions were not taken. This oversight had the potential to impact the resident's receipt of required services and care for her mental health conditions.
Failure to Administer Medications Timely
Penalty
Summary
The licensed nursing staff at the facility failed to adhere to professional standards of practice by not implementing the physician's written order for the administration of routine medications to Resident 13. Resident 13, who was admitted with diagnoses including COPD, hypertension, dementia, and depression, was supposed to receive several medications at 9:00 a.m. as per the Medication Administration Records. However, during an observation and interview, it was found that Resident 13 had not received her morning medications by 11:10 a.m., and she reported feeling dizzy. The medications included Amlodipine Besylate, Metoprolol Succinate, Aspirin, Sertraline, Folic Acid, and Albuterol Sulfate, which were crucial for managing her conditions. Licensed Vocational Nurse 3 admitted to not administering the medications on time, stating that she did not want to wake Resident 13, who was sleeping. This delay in medication administration was acknowledged by both LVN 3 and the Director of Nursing as a risk for health complications, including high blood pressure and heart attack. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed and according to the physician's orders, which was not followed in this instance.
Deficient Fingernail Care and Hygiene Maintenance
Penalty
Summary
The facility failed to provide adequate fingernail care and maintain grooming and personal hygiene for two residents who were unable to perform activities of daily living independently. Resident 52, who had diagnoses including diabetes, hypertension, dementia, and dysphagia, required maximum assistance for personal hygiene. During an observation, Resident 52 was found with long and dirty fingernails, and the resident expressed a desire for staff to clean and cut them. A Certified Nursing Assistant (CNA) acknowledged the condition of the resident's fingernails and stated that it was the responsibility of CNAs to clean and trim residents' fingernails daily. Similarly, Resident 77, who also had diagnoses of diabetes, hypertension, dementia, and dysphagia, required moderate assistance for activities of daily living. During an observation, Resident 77 was found with long and dirty fingernails. A Licensed Vocational Nurse (LVN) and a Registered Nurse (RN) both acknowledged the potential risks associated with long and dirty fingernails, such as infection and injury. The Director of Nursing (DON) confirmed that it was the CNAs' responsibility to ensure residents' fingernails were cleaned and trimmed as needed, in accordance with the facility's policy on activities of daily living.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
Facility staff failed to administer enteral nutrition as ordered for a resident, identified as Resident 27, who was receiving nutrition through a gastrostomy tube. The resident had been admitted with conditions including gastrostomy status, protein-calorie malnutrition, muscle wasting, atrophy, and dysphagia. The care plan for Resident 27 required tube feeding to maintain adequate nutritional and hydration status, with specific instructions for staff to administer enteral nutrition as ordered. However, during an observation, it was noted that the enteral nutrition was not being administered correctly, as the gastrostomy tube was closed, and the nutrition was spilling onto the floor and bed instead of being delivered to the resident. An interview with an LVN confirmed that the resident was not receiving the enteral nutrition as ordered, and there was uncertainty about how long the tube had been closed. The Director of Nursing acknowledged the importance of administering enteral nutrition as ordered to prevent potential decline in the resident's condition and unwanted weight loss. The facility's policy and procedure on enteral nutrition emphasized the need for regular inspection of tubing for proper and secure connections, which was not adhered to in this instance.
Failure to Follow IV Therapy Protocols
Penalty
Summary
The licensed nurses at the facility failed to adhere to the established policy and procedure for the initiation and maintenance of intravenous therapy for Resident 243. Specifically, they did not label and date the peripheral intravenous catheter (PIV) site, did not change the PIV site and dressing when it appeared compromised, and did not remove the PIV after the completion of IV treatment. These actions were observed during a survey, where the PIV dressing was found to be soiled, dislocated, and undated, and the resident expressed discomfort at the site. Resident 243 was admitted with multiple diagnoses, including diabetes, urinary tract infection, hypertension, and muscle weakness, and lacked the capacity to make decisions. The IV treatment with Ceftriaxone Sodium was completed, but the PIV was not removed as required. The facility's policy mandates that PIV dressings be changed if compromised and labeled with the date and time of the change, which was not followed in this case. This oversight had the potential to result in harm, including infection and phlebitis, for Resident 243.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for two residents, leading to potential discomfort and distress. Resident 47, who was admitted with a history of lumbar spinal fusion and chronic pain, requested pain medication for back pain at 10:32 a.m. on May 13, 2024. Despite the request being reported to a nurse, Resident 47 did not receive the prescribed Hydrocodone-Acetaminophen until 11:08 a.m., 36 minutes after the initial request. The care plan for Resident 47 indicated that staff should respond immediately to complaints of pain, but this was not adhered to, resulting in a delay in pain relief. Resident 61, admitted with reduced mobility and neuropathy following a stroke, did not have any medication ordered for breakthrough pain. On May 13, 2024, Resident 61 missed a scheduled 6:00 p.m. dose of Gabapentin, a medication for nerve pain. There was no documentation explaining why the medication was not administered, and the lack of breakthrough pain medication could lead to unnecessary pain. The care plan for Resident 61 required staff to anticipate pain relief needs and respond immediately to complaints of pain, but these interventions were not effectively implemented. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that pain management protocols were not followed. The DON emphasized that staff should promptly address pain complaints and that delayed administration of pain medication could cause resident discomfort. The failure to administer pain medication as ordered and the absence of breakthrough pain management for Resident 61 were identified as deficiencies in the facility's pain management practices.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster area in a sanitary manner. During an observation and interview with a maintenance staff member, it was noted that one of the three garbage dumpsters located outside the kitchen back exit was overfilled with cardboard boxes and left uncovered. Additionally, the ground around the dumpsters was littered with plastic utensils, gloves, and paper. The maintenance staff acknowledged that the cardboard boxes should be flattened to fit properly in the dumpster, allowing the lid to close, and that the area should be kept clean to prevent attracting pests. The facility's policies and procedures, as well as the FDA Food Code, require that outside dumpsters be kept closed and free of surrounding litter. The facility's policy on Food-Related Garbage and Refuse Disposal, revised in 2017, and the Sanitation policy, revised in 2022, both indicate that garbage and refuse containers should be in good condition, without leaks, and properly contained with lids or otherwise covered. The FDA Food Code further specifies that receptacles for refuse should be kept covered with tight-fitting lids or doors if kept outside, and stored in a manner that makes them inaccessible to insects and rodents.
Failure to Properly Explain Binding Arbitration Agreements
Penalty
Summary
The facility failed to adhere to its policy regarding the discussion of binding arbitration agreements with residents and their responsible parties. This deficiency was identified through interviews and record reviews involving three residents. For Resident 73, the responsible party signed the arbitration agreement without recalling any discussion or understanding of its implications. Similarly, Resident 80's responsible party signed the agreement, but there is no indication that the terms were explained or understood. Resident 241, who was self-responsible, also signed the agreement without recalling any explanation or understanding of what the agreement entailed. The facility's policy requires that the nature and implications of binding arbitration agreements be explained to residents or their representatives, ensuring their understanding before signing. The policy also mandates that verbal acknowledgment of understanding be documented by the staff member explaining the agreement. However, the Admissions Coordinator admitted to not documenting such verbal acknowledgments, despite being trained on the facility's policy. This oversight led to the residents and their responsible parties potentially forfeiting their right to resolve disputes in court without being fully informed.
Deficient Fingernail Care and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate fingernail care and maintain grooming and personal hygiene for two residents who were unable to perform activities of daily living independently. Resident 52, who had diagnoses including diabetes, hypertension, dementia, and dysphagia, required maximum assistance for personal hygiene. During an observation, Resident 52 was found with long and dirty fingernails, and he expressed a desire for staff to clean and cut them. A Certified Nursing Assistant acknowledged the condition of Resident 52's fingernails and stated that it was the responsibility of CNAs to clean and trim residents' fingernails daily. Similarly, Resident 77, who also had diagnoses of diabetes, hypertension, dementia, and dysphagia, required moderate assistance for ADLs. During an observation, Resident 77 was found with long and dirty fingernails and could not recall when they were last cleaned or trimmed. A Licensed Vocational Nurse and a Registered Nurse both highlighted the risks associated with long and dirty fingernails, including potential infections and injuries. The Director of Nursing confirmed that it was the CNAs' responsibility to ensure residents' fingernails were cleaned and trimmed as needed, as per the facility's policy on maintaining good grooming and personal hygiene.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 7,282 citations issued within 25 miles in the last 12 months — including the 36 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Los Angeles Doctors Hosp | 0.1 mi | ★★★★★ | 7 | 0 |
| Los Angeles Comm Hospital | 0.6 mi | ★★★★★ | 15 | 1 |
| Infinity Care Of East Los Angeles | 2.2 mi | ★★★★★ | 11 | 0 |
| Hollenbeck Palms | 2.6 mi | ★★★★★ | 21 | 0 |
| Maywood Skilled Nursing & Wellness Centre | 2.6 mi | ★★★★★ | 25 | 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.