Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Del Mar Convalescent Hospital during CMS and state inspections, most recent first.
A resident received docusate sodium without a verified dosage because the physician order listed tablets and the nurse administered two 100 mg tablets from house supply without clarifying the missing dose. In a separate event, an antibiotic count log for another resident did not match the remaining doses in the bubble pack, and the controlled substances shift count log was left incomplete and unsigned despite requirements for two nurses to verify and sign the count.
Missing Expiration Date on Resident Medication Label: A resident with hemiplegia, hemiparesis, brain neoplasm, and hypertensive heart disease with heart failure had Linzess ordered for chronic constipation, but during medication cart observation an LVN could not find an expiration/use-by date on the medication label. The LVN and DON both stated that expiration dates should be checked before administration, and the facility policy required expiration dates to be identified on medications.
Improper Labeling and Dating of Open Food Items: An open bag of diced broccoli in the freezer and two open cartons of milk in the refrigerator were not labeled or dated. The DS stated dietary staff had opened and used the items, but they were left without labels or dates, despite the facility P&P requiring refrigerated food to be labeled and dated.
Missing Staff COVID-19 Vaccination Documentation: The facility failed to maintain an updated log of staff COVID-19 vaccination status. During interview and record review, the DSD stated the only staff vaccination log available was from 2022 and an updated 2025-2026 log could not be found from the IPN. The facility policy required tracking and secure documentation of each staff member’s vaccine type, dose dates, and any booster doses.
A CNA was observed standing over a resident while assisting with lunch instead of being at eye level. The resident had CKD, Alzheimer's disease, and dementia with moderately impaired cognitive skills for daily decision making, and the resident was on a regular diet with liquidized texture and thin liquids. The CNA said she was standing because of back pain, while the LVN and DON stated feeding should be done at eye level or seated with the resident to support communication and observation during meals. The facility policy stated staff are to protect resident rights and promote dignity and respect.
Inaccurate MDS Omitted Depression Diagnosis: A resident’s MDS did not include the resident’s current depression diagnosis, even though the admission record listed major depressive disorder and a psychiatry note documented a history of depression with a plan to continue Cymbalta. The MDS also showed symptoms consistent with depression and a BIMS score indicating moderate cognitive impairment. The MDSC stated the diagnosis should have been entered and that it was omitted because the resident was not receiving antidepressant medication for depression.
Two residents had care plan interventions that were not carried out. One resident receiving Plavix had a care plan requiring monitoring for bleeding and bruising, but staff did not document such monitoring and the resident was observed with bruising on both forearms. Another resident with depression and mood-related symptoms had a care plan requiring monitoring for sadness, sleep changes, appetite changes, concentration, and psychomotor changes, but the report states those interventions were not monitored.
A resident with hemiplegia, hemiparesis, dysphagia, and aphasia had repeated diet changes, GT discontinuation after the tube was pulled and not replaced, and ongoing weight loss from 147 lbs to 139 lbs. The MDS Nurse confirmed only one nutritional assessment was completed, while the DS and DON stated no current nutritional assessment was found or completed when the resident’s diet changed or the GT was discontinued.
Failure to Monitor Antiplatelet Therapy Side Effects: A resident with stroke history, DM, pancytopenia, and severe cognitive impairment received Plavix daily, but the chart lacked documented monitoring or reassessment for side effects. The care plan called for monitoring bruising and other bleeding signs, yet the resident was observed with purplish bruises on both forearms, and the MDS Coordinator confirmed ongoing Plavix monitoring had not been followed. Staff interviews and record review also showed incomplete skin inspection documentation and no recent skin assessment available.
Resident Rooms Exceeded Allowed Occupancy: The facility failed to ensure seven resident bedrooms did not exceed the allowed number of occupants. Surveyors found rooms with five beds each, and some rooms had five residents while others had fewer occupants. The ADM stated the facility had room variances and would continue to apply for a Room Waiver. A CNA and a family member stated there was enough space for care in one of the shared rooms, and the facility policy required bedrooms to support adequate nursing care, comfort, and privacy.
The facility failed to follow its policy for preventing food contamination, as observed when multiple food items in the kitchen's refrigerator were unlabeled. The Assistant Kitchen Manager was unsure of when the items were opened or prepared, and the Dietary Supervisor confirmed that not labeling could lead to expired food being served. The facility's policy requires date marking of food items at the time of opening or preparation.
The facility was found non-compliant with regulations limiting resident room capacity, as seven rooms housed more than four residents each. Despite claims of adequate space, this practice contradicted the facility's policy, potentially limiting care and services.
The facility failed to ensure call lights were within reach for two residents, both with cognitive impairments and at risk for falls. One resident's call light was out of reach while in bed, and another's was inaccessible while in a wheelchair. Staff acknowledged the importance of call light accessibility for safety, as per facility policy.
The facility failed to ensure that the POLST and Advance Directive Acknowledgment Forms accurately reflected the advance directives of two residents. One resident's POLST and acknowledgment form were inconsistent, while another resident's POLST lacked any indication of an advance directive. These discrepancies were confirmed by the Social Services Assistant and the Director of Nursing, highlighting the importance of accurate documentation to honor residents' wishes.
The facility failed to notify the ombudsman and family representatives of two residents about their transfers to a General Acute Care Hospital. For one resident with chronic respiratory failure and Alzheimer's, there was no documented evidence of notification to the ombudsman or a signed notice by the representative. Another resident with intrahepatic bile duct carcinoma was transferred without confirmation of notice to the ombudsman, despite family notification. The facility's policy requires timely notice in urgent cases, but evidence of such notice was lacking.
The facility failed to ensure proper use of motion alarms for two residents at high risk for falls. One resident's alarm was not transferred from the wheelchair to the bed, and another's alarm was found disconnected. These oversights were contrary to the care plans, which required alarms to alert staff and remind residents to wait for assistance.
A resident in an LTC facility experienced a significant medication error when the route of administration for Droxidopa did not match the physician's order. The resident, with conditions including Parkinson's disease and dysphagia, was prescribed Droxidopa via G-tube, but an LVN administered it by dissolving the capsule powder in water. The error was identified during a medication pass observation, revealing a mismatch between the medication label and the MAR.
Medication order and controlled substance record inaccuracies
Penalty
Summary
The facility failed to ensure that a physician’s order for docusate sodium included the prescribed dosage before the medication was administered to a resident with diagnoses including unspecified atrial fibrillation and diabetes mellitus. The resident’s history and physical indicated the resident did not have the capacity to understand and make decisions. The physician’s order dated 12/9/2025 directed docusate sodium oral tablets, two tablets via gastrostomy tube, once daily for bowel management, but did not specify the dosage of the tablets. The MAR for 12/2025 also did not indicate the dosage administered. During medication administration observation, an LVN retrieved two docusate sodium tablets from house supply labeled 100 mg per tablet, crushed them, and administered them to the resident. In interview, the LVN stated she had been giving two 100 mg tablets because the order said tablets, and she did not clarify the missing dosage with the DON or physician. The DON confirmed the dosage had not been clarified before administration and stated the nurse should have clarified the dosage to prevent medication errors. The facility policy on Medication Administration required nurses to compare the medication source with the MAR to verify the resident name, medication name, form, dose, route, and time. The facility also failed to ensure accuracy of the Antibiotic and Controlled Drug Record Count log for another resident receiving cephalexin and failed to complete and sign the Controlled Substances Shift Count log for 12/17/25. The cephalexin order was for 500 mg by mouth three times daily for abnormal urinalysis, and the MAR showed the last dose was given at 9 AM. However, the count log documented the last dose at 9 AM and showed 4 remaining doses, while the bubble pack contained 5 remaining doses. The LVN stated the count log contained an error and that another nurse had documented a held dose, creating the discrepancy. The shift count log for the controlled substances cart was also left incomplete and unsigned for that shift, despite instructions requiring two licensed nurses to verify and sign the count at each shift change.
Missing Expiration Date on Resident Medication Label
Penalty
Summary
Medication labeling was not maintained in accordance with accepted professional principles when the facility failed to ensure that one resident’s Linzess oral capsule had an expiration or use-by date on the medication label. Resident 3 was admitted with hemiplegia, hemiparesis following cerebral infarction affecting the left non-dominant side, neoplasm of unspecified behavior of the brain, and hypertensive heart disease with heart failure. The resident’s history and physical indicated the resident did not have the capacity to understand and make decisions. The physician order was for Linzess 145 mcg by mouth once daily for chronic constipation, provided by family, to be given 30 minutes before the first meal, with instructions that the capsule may be opened and the contents not crushed or chewed. During a concurrent observation of medication cart storage with an LVN, the LVN was verifying Resident 3’s medication and stated she could not find the expiration/use-by date on the Linzess medication label. The LVN stated she would verify the order with the pharmacy and physician and explained that checking expiration dates was important to avoid giving expired medication and because expired medication may be less effective. The DON also stated that checking medication expiration dates before administration was important because an expired medication could have less effectiveness or side effects. The facility policy on medication administration stated that medications are to be administered as ordered and that expiration dates are to be identified, with expired medications reported to the nurse manager.
Improper Labeling and Dating of Open Food Items
Penalty
Summary
The facility failed to properly store food items in the kitchen, as one open bag of diced broccoli in the freezer was not labeled and dated and two open cartons of milk in the refrigerator were not labeled and dated. During observation and interview, the Dietary Supervisor stated that dietary staff had opened and used the broccoli and milk, but the items were left without labels or dates. The Dietary Supervisor also stated that open food items should be labeled and dated when first opened so staff would know how long they had been open and how long they would be good, and the facility policy titled Food Safety and Food Storage indicated that refrigerated food should be labeled and dated.
Missing Staff COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to maintain documentation of current COVID-19 vaccination status for staff. During a concurrent interview and record review with the Director of Staff Development, the only staff COVID-19 vaccination log available was from 2022, and an updated log for 2025-2026 could not be found from the Infection Prevention Nurse. The Director of Staff Development stated the last COVID-19 outbreak at the facility was in 10/2025 and acknowledged the importance of maintaining an updated list of staff vaccinations to know which employees to offer the COVID vaccine to and to prevent the spread of COVID. The facility policy titled Employee COVID-19 Vaccinations, revised 3/13/2023, required the facility to track and securely document each staff member’s vaccination status, including the specific vaccine received, dates of each dose, any scheduled next dose for a multi-dose vaccine, and any booster doses.
Feeding a Resident While Standing Over Them
Penalty
Summary
The facility failed to promote dignity and respect for one sampled resident when CNA 3 was observed standing over Resident 5 while assisting the resident with eating lunch. Resident 5 was admitted with chronic kidney disease, Alzheimer's Disease, and dementia, and the MDS dated 11/17/2025 indicated the resident had moderately impaired cognitive skills for daily decision making. The resident's physician orders dated 10/13/2025 directed a regular diet with liquidized texture and thin consistency. During a dining observation on 12/15/2025 at 12:32 PM, CNA 3 was standing over Resident 5 while feeding the resident, and the resident's bed was below the CNA's waist so the CNA was not at eye level with the resident. When interviewed, CNA 3 stated she was standing because she had back pain and acknowledged it was important to feed a resident at eye level to see how the resident was doing while eating and to make sure the resident was not choking. LVN 2 stated being at eye level while feeding allowed more contact with the resident and communication with the eyes. The DON stated staff assisting with feeding should be at eye level or seated with the resident to observe the resident while eating and to prevent aspiration. The facility's policy on Promoting/Maintaining Resident Dignity stated staff are to protect and promote resident rights and treat each resident with respect and dignity while recognizing each resident's individuality.
Inaccurate MDS Omitted Depression Diagnosis
Penalty
Summary
Resident 43’s MDS was not accurate because it did not reflect the resident’s current diagnosis of depression. The admission record showed that Resident 43 was admitted and later readmitted with diagnoses including neuropathy and major depressive disorder. The MDS dated [DATE] showed a BIMS score of 12, indicating moderate cognitive impairment, and a psychiatry progress note dated 10/12/2025 documented a history of depression with an adjustment disorder diagnosis and a treatment plan to continue Cymbalta. During interview and record review, the MDS coordinator stated that Resident 43’s diagnosis of depression should have been entered on the MDS. The MDS coordinator said the diagnosis was not entered because Resident 43 was not receiving antidepressant medication for depression, and after reviewing the RAI manual, stated the diagnosis should have been included on the assessment. The DON stated that the MDS identifies residents’ problems and should be accurate to direct and develop resident care planning. The facility’s policy for Resident Assessment - RAI stated that the comprehensive assessment includes disease diagnosis and health conditions.
Failure to Implement Care Plan Monitoring for Bleeding and Mood Symptoms
Penalty
Summary
The facility failed to ensure that care plan interventions were implemented for two sampled residents. Resident 8 was admitted with diagnoses including cerebral infarction, type 2 diabetes mellitus, and pancytopenia, and had a BIMS score of 6 indicating severe cognitive impairment. Resident 8 was receiving Plavix 75 mg daily, and the care plan for altered cardiovascular status directed staff to monitor, document, and report adverse reactions of antiplatelet therapy, including bruising and other signs of bleeding. During observation, Resident 8 was noted to have purplish discoloration and bruises on both forearms, and the resident could not explain how they occurred. The MDS Coordinator confirmed there was no documented evidence that the facility monitored for possible side effects of Plavix as required by the care plan. Resident 43 was admitted and readmitted with diagnoses including neuropathy and major depressive disorder, and had a BIMS score of 12 indicating moderate cognitive impairment. The MDS showed symptoms including feeling down, trouble sleeping, fatigue, poor appetite or overeating, feeling bad about self, and trouble concentrating. The resident’s mood care plan directed staff to monitor, record, and report acute episodes of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, changes in appetite and sleep patterns, diminished ability to concentrate, and changes in psychomotor skills. The Psychiatry Progress Note stated the resident had a history of depression and was currently stable with an adjustment disorder diagnosis. The DON stated that monitoring these symptoms was important, but the report states the interventions listed on the care plans for Residents 8 and 43 were not monitored.
Missing Nutritional Assessment After Diet Changes and Weight Loss
Penalty
Summary
The facility failed to ensure a nutritional assessment was completed for one sampled resident when the resident had a significant weight loss and multiple diet changes. The resident was admitted with hemiplegia, hemiparesis following cerebral infarction, dysphagia, and aphasia, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS dated 9/29/2025 showed the resident weighed 147 lbs and was on a physician-prescribed weight loss regimen due to weight loss of 5% or more in the last month or 10% or more in the last 6 months. The resident’s orders changed several times between NPO, pureed diet with moderately thick liquids, and later regular portions of pureed diet with moderately thick liquids. The resident’s GT was discontinued on 11/6/2025 due to family refusal to reinsert the GT after the resident pulled it out. Weekly weights showed a decline from 147 lbs on 9/27/2025 to 139 lbs on 12/17/2025, with multiple weights recorded in between. The care plan remained focused on alteration in nutritional status and included a registered dietitian consult due to risk of malnutrition. During interview and record review, the MDS Nurse stated only one nutritional assessment had been completed on 9/27/2025 and that no other nutritional assessment was done when the resident’s diet changed or when the GT was discontinued. The Dietary Supervisor stated nutritional assessments are to be completed on admission and when there is any change in diet, and she could not find a current nutritional assessment for the resident. The DON stated the RD completed a progress note but did not complete a nutritional assessment, and that the assessment should have been completed when the GT was pulled and the diet changed.
Failure to Monitor Antiplatelet Therapy Side Effects
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs by not adequately monitoring the resident’s continued need for Plavix (clopidogrel), an antiplatelet medication that may increase the risk of bleeding. The resident was admitted with diagnoses including cerebral infarction, type 2 diabetes mellitus, and pancytopenia. The resident’s MDS showed severe cognitive impairment with a BIMS score of 6, and the H&P stated the resident did not have the capacity to understand and make decisions. The resident received Plavix 75 mg daily from 11/10/2025 through 12/17/2025. The care plan for altered cardiovascular status directed staff to monitor, document, and report adverse reactions of antiplatelet therapy such as skin discolorations and bruises, and blood-tinged or red urine. During observation, the resident was seen with purplish discoloration and bruises on both forearms, and the resident did not know or remember how the discolorations occurred. The MDS Coordinator confirmed there was no documented evidence of monitoring or reassessment for Plavix side effects since admission and stated ongoing Plavix monitoring had not been followed. Additional interviews and record review showed the resident’s skin inspection form was last completed on 12/11/2025, with no recent form available, and the form documented no skin issues. Staff members including CNAs and OT stated they did not recall seeing bruising, and one CNA stated a skin inspection form was not completed after providing shower care. The DON stated residents on anticoagulant medications need monitoring and care plans for possible side effects such as bruising or bleeding, and that CNAs must report skin changes. The facility policy required weekly or change-of-condition skin assessments by a licensed or registered nurse and prompt notification of changes in condition.
Resident Rooms Exceeded Allowed Occupancy
Penalty
Summary
The facility failed to ensure resident bedrooms accommodated no more than four residents in seven of eighteen rooms, specifically Rooms 16, 19, 20, 21, 22, 25, and 26. During the survey, these rooms were identified as having five beds each, and the Client Accommodation Analysis form submitted by the facility also showed these rooms had more than four beds. The report states that this deficient practice had the potential to limit care and services and the ability of residents and staff to move easily in the room. During the recertification survey, surveyors observed that the seven rooms had varying occupancy levels, including rooms with five residents and no unoccupied beds, one room with four residents and one unoccupied bed, and one room with three residents and two unoccupied beds. The Administrator stated the facility had rooms with variances and would continue to apply for the Room Waiver. A CNA stated there was enough room to get around and provide care in one of the rooms, and a family member stated there was enough space for staff to care for his father in a five-resident room. The facility’s policy stated resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.
Failure to Label Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to its policy and procedures for preventing food contamination and the spread of foodborne illness in its kitchen. During an observation, multiple food items in the kitchen's refrigerator were found unlabeled, specifically four cups and one bowl of fruit mix. The Assistant Kitchen Manager (AK) confirmed that prepared and opened food items should be labeled with the date they were opened and their expiration date, but was unsure when these items were opened or prepared. In a follow-up interview, the Dietary Supervisor (DS) reiterated that opened items must have a label indicating the product name, opened date, and expiration date. The DS acknowledged that not following the facility's policy could harm residents, as unlabeled foods might be expired. The facility's policy, titled 'Date Marking for Food Safety,' requires the individual opening or preparing food to date mark it at the time of opening or preparation, including the date of opening and the date by which the item must be consumed or discarded.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as observed during a recertification survey. Specifically, seven rooms (Rooms 16, 19, 20, 21, 22, 25, and 26) were found to accommodate more than four residents, with each room containing five beds. This arrangement was confirmed through observations and interviews conducted between November 8 and November 10, 2024. The facility's Administrator acknowledged the situation, stating that the facility had rooms with variances and intended to apply for a Room Waiver. Despite the facility's claim that the rooms had adequate space for nursing care and that the multiple beds would not adversely affect residents' health and safety, the surveyors noted that this practice could potentially limit care and services. Observations included a family member's statement that there was enough space for staff to care for a resident in one of the rooms with five beds, and a resident being moved in a wheelchair without issues. However, the facility's policy and procedure, dated December 19, 2022, clearly indicated that resident bedrooms should not accommodate more than four residents, highlighting a discrepancy between practice and policy.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach, as required by the facility's policy and procedure. Resident 21, who has severe cognitive impairment and is dependent on assistance for activities such as toileting and bed mobility, was observed with a call light hanging on the left side of the bed, out of reach. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged the call light should be within reach. The Director of Nursing (DON) also emphasized the importance of call lights being accessible to prevent falls and ensure residents can request help. Resident 23, who has moderately impaired cognitive skills and is at risk for falls, was observed sitting in a wheelchair with the call light placed on the bed, more than three feet away, making it inaccessible. A CNA confirmed the placement of the resident by the window and acknowledged the call light was out of reach, stressing the importance of accessibility for resident safety. The DON reiterated the necessity of call lights being within reach to allow residents to call for assistance when needed. The facility's policy, titled "Call Lights: Accessibility and Timely Response," mandates that call lights be within reach and accessible to residents while in bed. The failure to adhere to this policy for Residents 21 and 23 highlights a deficiency in ensuring the safety and accommodation of residents' needs, potentially leading to accidents and falls.
Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) and Advance Directive Acknowledgment Form accurately reflected the advance directives of two residents. For one resident, the POLST indicated the presence of an advance directive, while the acknowledgment form stated otherwise, leading to a discrepancy. This resident, who was unable to make decisions due to medical conditions such as spinal stenosis and Parkinson's Disease, had an advance directive on file that was not acknowledged in the facility's records. The Social Services Assistant and the Director of Nursing confirmed the inconsistency, highlighting the importance of having accurate documentation to honor the resident's wishes in emergencies. Another resident, who had the capacity to make medical decisions despite a moderately impaired cognition, did not have an advance directive indicated in their POLST, nor was there evidence that an acknowledgment form was offered. This oversight occurred despite the facility's policy requiring the determination and documentation of advance directives upon admission. The Social Services Assistant noted the absence of this critical information, which is essential for understanding the resident's or responsible party's wishes in case of an emergency.
Failure to Notify Ombudsman and Family of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the resident's family representative and the ombudsman regarding the transfer of two residents, Resident 24 and Resident 54, to a General Acute Care Hospital (GACH). For Resident 24, the facility did not have documented evidence that the Notice of Proposed Transfer/Discharge was sent to the ombudsman or signed by the resident's representative. The resident, who had chronic respiratory failure and Alzheimer's disease, was transferred due to respiratory distress. The Director of Nursing (DON) confirmed the lack of documentation and emphasized the importance of notifying the resident's representative in writing. For Resident 54, the facility also failed to provide documented evidence that the notice of transfer was sent to the ombudsman. The resident, who had intrahepatic bile duct carcinoma and other medical conditions, was transferred out of the facility. Although the resident's family member was notified, there was no fax confirmation for the receipt of the notice by the ombudsman. The DON acknowledged the oversight and mentioned that there was still time to send the notice to the ombudsman. The facility's policy and procedure on transfer and discharge require that notice be provided to the resident, the resident's representative, and the LTC ombudsman as soon as practicable in cases of urgent medical needs. However, the facility did not maintain evidence that the notice was sent to the ombudsman in these cases, violating the residents' rights to be informed of their transfer/discharge and their rights to appeal.
Failure to Ensure Proper Use of Motion Alarms for Fall Prevention
Penalty
Summary
The facility failed to ensure that residents assessed at high risk for falls received appropriate care and services to minimize the likelihood of falls, as per the facility's fall prevention program. Specifically, the facility did not adhere to the care plan for two residents, Resident 6 and Resident 30, who were both identified as high fall risks. The care plans required the use of motion alarms to alert staff and remind residents to wait for assistance before attempting to move unassisted. For Resident 6, the deficiency occurred when the facility staff did not transfer the motion alarm from the resident's wheelchair to the bed after assisting the resident back to bed. The motion alarm was left attached to the wheelchair, contrary to the care plan's instructions. This oversight was observed during a visit, and the staff member involved acknowledged the error, stating that the motion alarm should have been moved to the bed to prevent the resident from attempting to get up unassisted. In the case of Resident 30, the motion alarm was found disconnected while the resident was in bed. The alarm was supposed to be connected and functioning at all times due to the resident's high fall risk and history of falling from bed. The disconnection was noticed during an observation, and the staff member reconnected the alarm, indicating that it should have been operational to alert staff of any unassisted movements by the resident. The Director of Nursing emphasized the importance of having the alarms in place and functioning to prevent falls and injuries.
Medication Administration Error Due to Route Discrepancy
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the route of administration for Droxidopa Oral Capsule did not match the physician's order on the Medication Administration Record (MAR). The resident, who was admitted with diagnoses including Parkinson's disease and dysphagia, was prescribed Droxidopa to be administered via a gastrostomy tube (G-tube). However, during a medication pass observation, a Licensed Vocational Nurse (LVN) was seen administering the medication by opening the capsules and dissolving the powder in water, which did not align with the prescribed G-tube administration. The discrepancy was identified when the LVN verified the medication bottle and MAR, confirming that the instructions on the medication label did not match the physician's order. The Director of Nursing (DON) acknowledged that the primary physician was unaware of the discrepancy and emphasized the importance of ensuring that medication orders match the physician's instructions to prevent errors. The facility's policy requires that medication sources be compared with the MAR to verify details such as resident name, medication name, form, dose, route, and time, which was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rosemead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monterey Park Conv Hosp | 1.1 mi | ★★★★★ | 0 | 0 |
| Heritage Manor | 1.2 mi | ★★★★★ | 7 | 0 |
| San Gabriel Conv Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Green Acres Healthcare Center | 1.5 mi | ★★★★★ | 12 | 0 |
| Monterey Healthcare & Wellness Centre, Lp | 1.6 mi | ★★★★★ | 22 | 0 |
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