Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at El Centro Post-acute Care during CMS and state inspections, most recent first.
Resident rooms had peeling wallpaper, exposed drywall, removed baseboards, hanging cords, damaged boards, and exposed cable boxes, leaving several rooms without a homelike appearance. Residents and family members described the rooms as tacky, unkept, or not in good condition, and the MD, ADM, and DON acknowledged the rooms were not homelike and that repairs were needed. One resident with hemiplegia and cerebral infarction reported that no one cared what the room looked like, while another resident with dementia had exposed drywall and removed baseboards in the room.
Unsafe bathroom and shower room conditions: A resident’s toilet seat was loose and moved from side to side, and the resident said it had been that way since admission and that he had asked staff to fix it. Staff observations confirmed the seat was not tightened, and the maintenance book had no entry for the repair. In addition, two shower rooms had protruding orange screws and a broken soap dish with jagged edges; the CNA, DON, MD, and ADM all acknowledged these were safety hazards.
Expired fish was found in the walk-in refrigerator during an observation with the DS. The fish was covered with plastic and labeled with an expiration date that had already passed, and the DS stated it should have been discarded. Facility policy stated that expired or outdated food products should be discarded.
Infection control standards were not maintained when shower stalls had black residue in the grout, streaks on the tiles, and hair on the floor, and staff described the area as not clean and possibly moldy. A resident receiving a nebulizer treatment also had a mask labeled with an old date, while the RT and DON stated the nebulizer tubing and mask were to be changed weekly for infection control.
Failure to maintain dignity during meal assistance: A CNA was observed feeding a resident with metabolic encephalopathy while standing approximately 2 feet over the resident's head. The CNA said she believed standing while feeding was acceptable, while other staff and the DON stated meal assistance should be provided at eye level to show respect and support dignity, consistent with the facility's meal assistance policy.
Failure to Follow Antiplatelet Monitoring Care Plan: A resident admitted with atherosclerotic heart disease was ordered Clopidogrel 75 mg daily for CVA prevention, and the care plan identified a risk for active bleeding with interventions to observe for signs of abnormal bleeding such as bleeding gums, nosebleeds, and black/tarry stools. LN and DON interviews confirmed that nursing staff did not follow the care plan by monitoring and documenting negative side effects for the resident on a blood thinner.
Improper G-tube Medication Administration: A nurse failed to verify G-tube placement before giving medications, crushed and combined multiple meds into one mixture, and used a syringe plunger instead of gravity to administer the medication and flush. The resident had hemiplegia and dysphagia, and the physician’s order and facility policy both required placement checks and separate administration of meds through the tube.
Lack of Monitoring for Anticoagulant Side Effects: A resident receiving Clopidogrel Bisulfate for CVA prevention had no documented monitoring for negative side effects of the blood thinner. An LPN stated the documentation was missing, the pharmacist identified expected side effects such as bleeding and bruising, and the DON stated licensed nurses should have monitored and documented negative side effects for residents on a blood thinner.
A nurse administered four medications incorrectly to a resident with a G-tube, crushing them individually and combining them into one mixture before attempting to push the solution through the tube. The resident had diagnoses including stroke-related right-sided weakness and dysphagia, and the record included orders for G-tube placement checks, specific preparation instructions for tamsulosin, and an order for cephalexin by mouth rather than via G-tube. Interviews showed the nurse lacked G-tube medication administration training, while another nurse and the facility policy required medications to be given separately with flushes between doses.
A resident with dysphagia and a G-tube had a Cephalexin order documented as by mouth instead of via GT. The DON stated the order should have been documented as via GT and that licensed nurses were expected to accurately document physician orders.
A resident with a fractured right humerus experienced severe pain, but the facility failed to administer the correct dosage of Oxycodone as per physician's orders. Despite reporting pain levels of 7 to 9, the resident received a lower dosage of 5mg instead of the prescribed 10mg for severe pain. This error was acknowledged by the LPN and confirmed by the DON, highlighting a lapse in following the facility's pain management protocol.
The facility failed to properly dispose of garbage and refuse, with one trash dumpster missing a lid and recycle dumpsters overfilled, preventing lids from closing. Staff interviews revealed a lack of awareness and immediate action regarding the issue, contrary to the facility's Waste Management policy.
The facility failed to conduct N95 respirator fit testing for staff working with COVID-19 positive residents, despite having policies in place. Additionally, a CNA did not change gloves during catheter care for a resident with a urinary tract infection, risking contamination. Staff interviews confirmed the need for proper infection control practices.
The facility failed to ensure accurate PASRR Level 1 screenings for three residents, omitting diagnoses such as psychosis, bipolar disorder, and schizophrenia. The Admissions Coordinator and MDS Coordinator acknowledged the discrepancies, indicating a lapse in updating the screenings after reviewing hospital records.
The facility failed to ensure accurate MDS assessments for two residents. One resident with schizophrenia was inaccurately reported as not having a serious mental illness, despite needing specialized services. Another resident discharged home was incorrectly documented as discharged to a hospital. The MDS Coordinator, DON, and Executive Director acknowledged the inaccuracies and stressed the importance of accurate MDS for care and billing.
A resident with a diabetic ulcer was readmitted to an LTC facility without a physician's order for wound care, resulting in a lapse in treatment. Despite facility policy requiring immediate assessment and physician notification for treatment orders, staff failed to resume or obtain new orders, leaving the ulcer untreated for several days. Interviews with staff revealed a breakdown in communication and procedure adherence.
Two residents did not receive their physician-ordered medications due to unavailability. One resident with GERD and a peptic ulcer did not receive pantoprazole sodium for several days, while another resident with osteomyelitis and diabetes did not receive ketotifen fumarate ophthalmic solution due to back order or insurance issues. The DON and Executive Director confirmed that the medications should have been available and administered.
A resident with severe cognitive impairment was prescribed lorazepam without an end date. The consultant pharmacist recommended adding a stop date, but the facility failed to follow up on this recommendation. Interviews revealed confusion among staff about their roles in addressing pharmacy recommendations.
A resident with severe cognitive impairment had a PRN order for lorazepam without a specified 14-day stop date, contrary to facility policy. Despite reminders from the Consultant Pharmacist, the attending physician did not add a length of therapy. Interviews with staff confirmed the oversight.
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.14%. Two residents were affected: one received an incorrect dosage of vitamin D3 due to unavailability of the prescribed dose, and another did not receive prescribed eye drops due to supply issues. The DON and Executive Director expected medications to be available and regulations followed.
A resident with severe cognitive impairment and a history of cerebral ischemia and atrial fibrillation was administered losartan potassium and metoprolol tartrate despite physician orders to hold the medications if the resident's systolic blood pressure was below 120 mmHg. Facility staff, including an LVN, ADON, DON, and Executive Director, confirmed that the blood pressure parameters were not followed.
A resident admitted for hospice care did not have a physician's order for hospice services documented, as required by facility policy. Despite being admitted with a terminal prognosis, the order was missing from the medical records. Staff interviews revealed a lack of awareness and action to obtain the necessary order, indicating a deficiency in the facility's hospice care coordination process.
A resident's right to receive visitors was violated when their daughter was denied entry after a fall incident due to the facility's after-hours policy. Despite the resident's request for hospital transfer and the daughter's arrival, staff interviews indicated that exceptions should be made in such situations. The facility's policy guarantees residents the right to be visited, highlighting a deficiency in honoring this right.
A resident with diabetes and gastrostomy was observed to have a tube feeding order discrepancy in the facility. The physician's order specified Glucerna 1.5 at 60 ml/hr for eight hours, but the MAR indicated 50 ml/hr for 20 hours, which was consistently signed by licensed nurses. The Registered Dietitian and Assistant Director of Nursing noted the mismatch, which could affect the resident's weight and oral intake. The facility did not provide a relevant policy.
The facility failed to protect a resident from sexual abuse when another resident's wandering behavior was not assessed, leading to a non-consensual sexual encounter. Despite staff awareness of the wandering and aggressive behaviors, no proper assessment or care plan was in place, resulting in a serious breach of resident safety and rights.
The facility failed to assess a resident's wandering behavior and develop a baseline care plan within 48 hours of admission. This led to the resident entering other residents' rooms and engaging in inappropriate behavior, including a sexual act. Despite frequent observations of wandering and aggression, no formal assessment or care plan was created.
Resident rooms were left with damaged walls, exposed fixtures, and unfinished repairs
Penalty
Summary
The facility failed to maintain resident rooms in a safe, clean, comfortable, and homelike condition. Survey observations identified multiple rooms on Station 1 and Station 2 with peeling wallpaper, exposed drywall, removed or damaged baseboards, exposed cables and cable boxes, hanging cords, and other unfinished or broken room features. The report stated these conditions were present in rooms for Residents 54, 118, 119, 122, 137, 5, 20, 51, and 90. Resident 20, who had hemiplegia and cerebral infarction, was observed in a room with an olive-green wall marked by white streaks and a cable box with cords hanging down from it. The resident stated the cable box had been like that for a long time and said she felt like no one cared what her room looked like. Resident 90, who had intervertebral disc disorder, muscle weakness, and dementia, was observed in a room with scraped paint exposing white drywall behind the headboard and a removed baseboard exposing drywall near the garbage can. The Maintenance Director stated the hanging power supply cables, cable boxes, and wires had been in many resident rooms for a while and was not sure when they would be repaired, and stated exposed drywall should have been fixed immediately. Additional room observations showed Resident 5’s room with a removed baseboard exposing drywall, exposed cables hanging from a power supply cable box, an empty cable box bracket, and painted-over drywall anchors; Resident 51’s room with scraped paint exposing drywall behind the headboard; Resident 118’s room with a plastic trash bag tied to an overhead light cord; Resident 119’s room with a broken splintered wooden board near the bed and an overhead light cord that the resident could not reach; Resident 122’s room with plastic bags tied around the siderail and overhead light cord, plus damaged walls in the room and bathroom; Resident 137’s room with torn and peeling wallpaper and an uncovered phone socket; and Resident 54’s room with peeling wallpaper. The Administrator and DON stated the rooms were not homelike and that repairs were needed, and the DON stated staff were expected to identify repairs and document them in the maintenance repair book.
Unsafe bathroom and shower room conditions
Penalty
Summary
The facility failed to provide a safe, nonhazardous environment when a bathroom used by one resident had a loose toilet seat that moved from side to side and had not been tightened down. The resident stated the toilet seat had been loose since admission and that he had asked numerous staff to fix it. He also stated he was afraid he would fall every time he used the bathroom. The resident’s record showed he was admitted with diagnoses including surgical aftercare following an intestinal obstruction, and his MDS dated 12/30/25 indicated a cognitive score of 13 with intact cognition and that he was independent and able to ambulate without assistive devices. An observation of the bathroom confirmed the toilet seat moved from side to side when touched and needed to be tightened. Review of the station maintenance book showed no documented evidence that the loose toilet seat had been identified or that a repair had been requested. During interviews, a CNA observed the loose seat and stated someone could fall when trying to sit down or stand up, and that the repair should have been entered into the maintenance book right away. An LN also observed the loose seat and stated it was definitely a safety issue. The ADM later observed the seat and stated it should have been reported and fixed, and that if the resident told staff about it, staff should have entered the repair in the maintenance book. The facility also had hazards in two resident shower rooms. During observation, CNA 4 identified orange-colored screws protruding from the tile near the handlebar, under the faucet, and next to the shower handlebar in one shower room, and stated she did not know why the screws were there. CNA 4 stated that if a resident brushed against a screw it could cause a skin tear, scrape, or injury. The DON observed the same shower room and stated the screws were sticking out from the tiles, the white porcelain soap dish was broken with jagged edges, and both conditions were potential safety hazards because someone could get cut or scrape their skin. The MD stated he should have removed the protruding screws because someone could get hurt, and the ADM stated the showers needed to be worked on and the screws needed to be removed. The facility policy stated maintenance service was to keep the building, grounds, and equipment in a safe and operable manner and free from hazards.
Expired Fish Found in Walk-In Refrigerator
Penalty
Summary
Food storage practices were not followed when expired fish was found in the walk-in refrigerator during a concurrent observation and interview with the Dietary Supervisor. On 1/6/26 at 8:30 A.M., surveyors observed a tray of fish covered with plastic and labeled with an expiration date of 1/5/26. The Dietary Supervisor stated the fish should have been discarded because it was expired. A facility policy titled Food Storage, dated 8/29/23, stated that any expired or outdated food products should be discarded.
Infection Control Lapses in Shower Room Cleaning and Nebulizer Equipment Changes
Penalty
Summary
The facility failed to implement and maintain infection control standards of practice in two shower rooms and in the care of a resident receiving nebulizer treatment. During observation of one shower stall, surveyors found dark black residue in the grout and on the tiles of the wall and floor, along with dark brownish-orange streaks on some tiles and next to the handrail, and hair on the floor. Licensed nurses, the DON, the Administrator, and the Maintenance Director all stated the shower did not appear clean, with comments that the black substance looked like mold and that rust was present. Staff also stated the shower had not been cleaned between residents and that shower stalls were expected to be cleaned and disinfected after use. In a separate observation, Resident 89, who was admitted with generalized muscle weakness, was receiving a nebulizer breathing treatment and had a mask labeled with a date of 12/28/25. The Respiratory Therapist stated the mask should be changed weekly and had not noticed the date on the mask, and the DON stated it was the facility expectation and policy that nebulizer tubing and mask be changed weekly for infection control. The facility policy also stated the nebulizer administration set up should be discarded every seven days.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote dignity while assisting a resident with a meal by having a CNA stand over the resident during feeding. Resident 70 was admitted with diagnoses including metabolic encephalopathy. During an observation at lunch, the resident was in bed receiving a pureed diet while the CNA stood on the right side of the bed approximately 2 feet over the resident's head as she fed the resident. During interview, the CNA stated she thought it was alright to stand while feeding residents and that no one had told her otherwise. Other staff interviewed stated that staff should be at eye level when feeding residents, and that sitting eye-to-eye was important to show respect, encourage socialization, and identify early signs of choking. The DON also stated staff were expected to sit at eye level when assisting residents with meals, either by sitting next to the resident or raising the bed to maintain eye-to-eye level. The facility policy on Assistance with Meals stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals.
Failure to Follow Antiplatelet Monitoring Care Plan
Penalty
Summary
The facility failed to implement a care plan related to monitoring an anticoagulant for one of nine residents reviewed for care plans, Resident 42. Resident 42 was admitted with diagnoses that included atherosclerotic heart disease, and the physician’s order indicated Clopidogrel Bisulfate 75 mg by mouth daily for CVA prevention. The resident’s care plan titled Antiplatelet Care Plan identified a risk for active bleeding and listed interventions to observe for signs and symptoms of abnormal bleeding such as bleeding gums, nosebleeds, and black/tarry stools. During interview and record review, LN 20 reviewed the care plan and physician’s order and stated it was important to monitor and document negative side effects for patient safety, and that the care plan should have been followed. During a later joint interview, the DON stated licensed nurses should have monitored and documented negative side effects for residents on a blood thinner, and that her expectation was for nursing staff to follow residents’ care plans. The facility policy titled Care Plan stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident, and that assessments are ongoing and care plans are revised as residents’ conditions change.
Improper G-tube Medication Administration
Penalty
Summary
The facility failed to demonstrate nursing standards of practice during medication administration via a G-tube for one resident with a history of hemiplegia following cerebral infarction affecting the right side and dysphagia. During observation, a licensed nurse prepared four medications by crushing them individually, then combined them into one clear plastic medication cup with 30 cc of water before administration. The nurse then attempted to give the diluted medication through the resident’s G-tube using a 60 cc syringe and the syringe plunger, rather than administering by gravity. Before starting the medication administration, the nurse did not check the G-tube for proper placement. When resistance was encountered during administration, another nurse obtained a new 60 cc syringe after three attempts with the original syringe, and the medication was then pushed into the tube using the syringe plunger. The nurse also used the plunger to push 30 cc of water into the G-tube after the medication was given. During interview, the nurse stated she had been taught to check G-tube placement but did not do so, and stated she had not received training for G-tube medication administration when she started at the facility. Record review showed the physician had ordered that G-tube placement be checked before administering medication and that Tamsulosin be opened and mixed with 10 cc of water for immediate administration. The record also showed cephalexin ordered by mouth, not by G-tube, for cellulitis to the stoma. The facility’s policy required verification of tube placement, administration of each medication separately, and administration by gravity flow with flushing between medications. The DSD stated she expected nurses to check placement, administer medications separately, and use gravity flow, and later stated she had marked G-tube medication administration as not applicable on the nurse’s skills checklist because she had not observed it. The DON stated the medications were not administered properly and should have been.
Lack of Monitoring for Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring was provided for one resident receiving an anticoagulant medication. Resident 42 was admitted with a diagnosis that included atherosclerotic heart disease, and the physician’s order included Clopidogrel Bisulfate 75 mg by mouth daily for CVA prevention. During interview and record review, the licensed nurse stated there was no documentation showing monitoring for the negative side effects of the blood thinner, and stated that such monitoring should have been documented for resident safety. A telephone interview with the pharmacist identified the general side effects of Clopidogrel Bisulfate as abnormal bleeding, bruising, abdominal pain, bloody stools, and nosebleeds, and stated that monitoring for negative side effects should have been documented. The pharmacist also stated that the lack of documentation should have been identified during the monthly medication review. During a joint interview, the DON stated licensed nurses should have monitored and documented negative side effects for residents on a blood thinner. The facility policy titled Anticoagulant stated that staff and the physician will monitor for possible complications in individuals who are being anticoagulated.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below five percent during a random medication pass observation for one resident who had diagnoses including hemiplegia following cerebral infarction affecting the right side and dysphagia. During the observation, a licensed nurse removed four medications for the resident—tamsulosin 0.4 mg, finasteride 5 mg, clopidogrel 75 mg, and cephalexin 500 mg—crushed them individually, combined them into one clear plastic medication cup, added 30 cc of water, and then attempted to administer the mixture through the resident’s G-tube. The medication solution turned white, and the nurse had resistance when trying to push it through the tube, requiring another syringe after several attempts. The resident’s record showed orders to check G-tube placement before administering medication and to give tamsulosin by opening the capsule, mixing it with 10 cc of water, and administering it immediately to prevent beads from clumping. Another order dated 1/4/26 directed cephalexin 500 mg to be given by mouth every four hours for cellulitis at the stoma, not via G-tube. During interview, the nurse stated she had not received training for G-tube medication administration and said she had been trained in nursing school to combine medications and administer them together. Another nurse stated crushed medications should be administered separately via G-tube with flushes in between. The facility’s policy required each medication to be administered separately and the tube to be flushed between medications.
Medication Order Documented by Wrong Route
Penalty
Summary
The facility failed to ensure a medication order was accurately documented for one of ten sampled residents, Resident 72. Resident 72 was admitted with diagnoses including dysphagia and gastrotomy with a G-tube. On 1/1/26, a physician order for Cephalexin 200 mg tablet, 1 tablet four times a day by mouth for cellulitis to the stoma until 1/12/26 was entered into the clinical record. During record review on 1/8/26, the order was found documented as by mouth even though the resident receives medications via G-tube. During an interview on 1/9/26, the DON stated the medication order should have been documented as via GT and not by mouth, and stated it was her expectation that licensed nurses accurately document physician orders.
Failure to Administer Correct Pain Medication Dosage
Penalty
Summary
The facility failed to administer the correct dosage of pain medication as per the physician's orders for a resident who required pain management. The resident, who was cognitively intact and had a history of a fractured right humerus, was observed in pain with a pain score of 8 out of 10. Despite the physician's orders specifying that Oxycodone 10mg should be administered for severe pain levels of 7 to 10, the resident was given Oxycodone 5mg instead. This occurred on multiple occasions, as documented in the Electronic Medical Administration Record, where the resident received the lower dosage for severe pain levels ranging from 7 to 9. During an interview, the Licensed Nurse acknowledged the error, stating that the resident should have received the higher dosage for severe pain. The Director of Nursing also confirmed that the resident should have been given Oxycodone 10mg for pain levels of 7 or above, as per the physician's orders. The facility's policy on pain management emphasizes the importance of using a consistent approach and standardized pain assessment to ensure appropriate interventions. The failure to administer the correct dosage of pain medication had the potential to cause the resident further discomfort and delay in healing.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, affecting one trash dumpster and two recycle dumpsters. An observation revealed that one trash dumpster was missing a lid, exposing its contents to the open air. Additionally, the recycle dumpsters were overfilled with cardboard boxes, preventing the lids from closing. This situation was contrary to the facility's Waste Management policy, which mandates that dumpsters must be kept closed to prevent pest attraction and odor spread. Interviews with facility staff, including the Certified Dietary Manager, Director of Maintenance, and Maintenance Assistant, indicated a lack of awareness and immediate action regarding the missing lid and overfilled dumpsters. The Director of Maintenance acknowledged the issue and stated that the dumpster company was contacted to replace the missing lid. The Director of Nursing and Executive Director expressed expectations that the dumpsters should be enclosed and maintained by the maintenance department, although they were not aware of specific regulations related to dumpster management.
Infection Control Deficiencies in Respirator Fit Testing and Hand Hygiene
Penalty
Summary
The facility failed to ensure that staff were fit tested for N95 respirators, which are required for respiratory protection when working with COVID-19 positive residents. Despite having policies in place that specified the use of N95 respirators, interviews with the Infection Preventionist, Director of Nursing, and Executive Director revealed that the facility was not conducting any N95 fit testing. The Infection Preventionist admitted to not knowing that fit testing was required until August 2024, and the facility was using KN95 masks instead. This oversight had the potential to affect all residents in the facility. Additionally, the facility failed to maintain proper hand hygiene during catheter care for a resident with a urinary tract infection. During an observation, a CNA did not change gloves between handling soiled items and clean items, which could lead to contamination. The CNA acknowledged the mistake, stating that gloves should be changed to prevent the spread of infection. Interviews with other staff, including the Infection Preventionist and Director of Nursing, confirmed that gloves should be changed between tasks to adhere to infection control practices.
Inaccurate PASRR Level 1 Screenings for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level 1 for three residents. Resident #37 was admitted with a medical history of unspecified psychosis and anxiety disorder, but the PASRR Level 1 Screening did not list the diagnosis of psychosis. The Admissions Coordinator acknowledged that the PASRR was completed at the hospital and should have been corrected by the facility to include the psychosis diagnosis. Resident #91 was admitted with a diagnosis of bipolar disorder, but the PASRR Level 1 Screening indicated that the resident did not have any serious mental illness. The Admissions Coordinator confirmed that the PASRR should have included the bipolar disorder diagnosis, indicating a failure to update the screening accurately after reviewing hospital records. Resident #71 had a history of bipolar disorder, major depressive disorder, and anxiety disorder, with active diagnoses of anxiety, depression, and bipolar disorder. However, the PASRR Level 1 Screening only reflected the diagnosis of anxiety, omitting bipolar disorder and schizophrenia. The MDS Coordinator and the Director of Nursing both acknowledged the need for an updated PASRR to reflect the resident's diagnoses, highlighting a lapse in the facility's process to ensure accurate PASRR documentation.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for two residents, leading to deficiencies in their assessments. Resident #60 was admitted with a diagnosis of schizophrenia and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. However, the MDS inaccurately reported that the resident was not considered by the state Level II PASRR process to have a serious mental illness, despite a Level II evaluation indicating the need for specialized services due to a medical and/or mental health condition. Interviews with the MDS Coordinator, Director of Nursing (DON), and Executive Director confirmed the inaccuracy of the MDS and the expectation for accurate assessments. Resident #118 was admitted with a medical history including cerebral infarction, type two diabetes mellitus, and chronic kidney disease. The resident was discharged home after completing skilled nursing and rehabilitation services. However, the discharge MDS inaccurately indicated that the resident was discharged to a short-term hospital instead of their home. The MDS Coordinator acknowledged the inaccuracy, and both the DON and Executive Director emphasized the importance of MDS accuracy for providing adequate care and billing purposes.
Failure to Obtain Physician's Order for Diabetic Ulcer Treatment
Penalty
Summary
The facility failed to obtain a physician's order for the treatment of a diabetic ulcer for a resident, leading to a lapse in care. The resident, who had a medical history of type 2 diabetes mellitus and a diabetic foot ulcer, was readmitted to the facility after a hospital stay. Upon readmission, the resident's wound care orders were not resumed, and no new orders were obtained, resulting in a lack of treatment for the ulcer from the time of readmission until several days later. The facility's policy required that upon identification of a wound, a licensed nurse should conduct an initial assessment, document the wound's characteristics, and notify the attending physician to obtain treatment orders. However, this process was not followed. The resident's wound evaluation noted the presence of a diabetic ulcer with signs of infection, but the treatment nurse failed to ensure an active order for care was in place. The resident reported that no treatment had been provided since their return from the hospital. Interviews with facility staff, including the RN responsible for the initial assessment and the LVNs assigned to the resident, revealed a lack of communication and follow-through in obtaining necessary treatment orders. The nurse practitioner acknowledged the lapse in treatment, although he believed it would not significantly impact the wound's healing. The Director of Nursing and Executive Director both expressed that staff should have reviewed and resumed the resident's wound care orders to ensure continuous care.
Failure to Provide Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available for two residents, leading to a deficiency in pharmaceutical services. Resident #75, who was admitted with a medical history of gastro-esophageal reflux disease (GERD) and an acute peptic ulcer, did not receive their prescribed pantoprazole sodium for several days. Despite the medication being dispensed, it was not available for administration from 09/03/2024 through 09/08/2024. Interviews revealed that the medication was destroyed, but the reason for this was unknown. The Director of Nursing (DON) and other staff confirmed that the medication should have been available and administered as per the physician's order. Similarly, Resident #171, admitted with osteomyelitis and diabetes, did not receive their prescribed ketotifen fumarate ophthalmic solution due to unavailability. The medication was not administered from 09/06/2024 through 09/09/2024, as it was either on back order or not covered by insurance. The DON and Executive Director acknowledged that the medication should have been available and administered. The deficiency was identified through interviews, record reviews, and observations, highlighting a failure in the facility's pharmaceutical services to meet the needs of these residents.
Failure to Address Pharmacy Recommendations for PRN Medication
Penalty
Summary
The facility failed to ensure timely follow-up on pharmacy recommendations for a resident reviewed for unnecessary medications. The resident, who was admitted with a history of dementia and major depressive disorder, had a severe cognitive impairment as indicated by a BIMS score of 5. The resident was prescribed lorazepam, an antianxiety medication, on an as-needed basis without an end date. The consultant pharmacist noted the absence of a stop date for the PRN psychotropic medication in both June and July reviews and advised the facility to add a length of therapy. However, the physician did not sign the recommendations, and the issue remained unaddressed. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for addressing pharmacy recommendations. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were responsible for completing pharmacy recommendations, but the ADON was unaware of why the recommendations were not addressed. The DON admitted to not understanding her role in the process and had been placing the recommendations in the nurse practitioner's box. The Executive Director also did not know why the recommendations were not followed, despite it being facility practice to address them.
Failure to Specify Duration for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN order for psychotropic medication specified the duration of use for a resident with severe cognitive impairment. The resident, who had a medical history of dementia and major depressive disorder, was admitted to the facility and had a PRN order for lorazepam to be administered every six hours as needed for anxiety and restlessness. However, the order did not include a 14-day stop date as required by the facility's policy on psychotropic medication use. Despite the Consultant Pharmacist's notes to the attending physician on two separate occasions, requesting the addition of a length of therapy for the PRN lorazepam, the physician did not sign the document. Interviews with the Consultant Pharmacist, a Licensed Vocational Nurse, the Assistant Director of Nursing, the Director of Nursing, and the Executive Director confirmed that the PRN lorazepam order lacked the required 14-day stop date, which was expected to be included in the physician's order.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.14% during the survey. This deficiency was identified through observations, interviews, and record reviews. Two medication errors were noted among six residents reviewed. The first error involved a resident with a history of protein-calorie malnutrition and osteoarthritis, who was prescribed vitamin D3 1000 units daily. However, the resident was administered vitamin D3 2000 units because the correct dosage was unavailable. The LVN responsible acknowledged the error and stated that the physician should have been notified about the unavailability of the correct dosage. The second error involved a resident with osteomyelitis and type 2 diabetes mellitus, who was prescribed ketotifen fumarate ophthalmic solution for itchiness. The medication was not administered because it was unavailable due to being on back order or not covered by insurance. The resident confirmed not receiving the eye drops since admission. The LVN confirmed the non-administration of the medication, and the Director of Nursing and Executive Director both expressed expectations for medication availability and adherence to regulations.
Failure to Follow Blood Pressure Parameters for Medication Administration
Penalty
Summary
The facility failed to prevent a significant medication error for a resident with severe cognitive impairment and a medical history of cerebral ischemia and atrial fibrillation. The resident was prescribed losartan potassium and metoprolol tartrate, both with specific instructions to hold the medication if the resident's systolic blood pressure (SBP) was less than 120 mmHg. Despite these instructions, the facility staff administered these medications multiple times when the resident's SBP was below the specified threshold. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Executive Director, confirmed that the blood pressure parameters were not followed as per the physician's orders. The LVN acknowledged administering the medications against the parameters, and both the ADON and DON confirmed that the staff did not adhere to the prescribed guidelines. The Executive Director also stated that the expectation was for staff to follow the physician-ordered parameters.
Failure to Obtain Hospice Order for Resident
Penalty
Summary
The facility failed to obtain a physician's order for hospice services for Resident #221, who was admitted for hospice care. The facility's policy requires the Director of Nursing (DON) to coordinate care and obtain necessary hospice orders, but this was not done. Resident #221 was admitted with a terminal prognosis and required hospice services, as indicated in their care plan. However, the Order Summary Report did not include an order for hospice care, and multiple staff members, including a hospice aide and licensed vocational nurses, confirmed the absence of such an order. Interviews with facility staff revealed a lack of awareness and action regarding the missing hospice order. The DON and Executive Director both stated that they expected nursing staff to obtain and document hospice orders upon admission. Despite this expectation, the order was not entered into the medical records, indicating a breakdown in the facility's process for managing hospice admissions. This oversight was identified during a survey, highlighting a deficiency in the facility's compliance with its own policies and procedures for hospice care coordination.
Resident's Right to Visitors Denied After Fall Incident
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing, which resulted in a deficiency. The incident involved a resident who was admitted with diagnoses including weakness and an unspecified fall. On a specific date, the resident was found on the floor, resistant, and yelling in Spanish. The resident refused assessment and requested to be transferred to the hospital, which was facilitated by calling 911. The resident's daughter arrived at the facility following the incident but was denied entry due to the facility's policy of not allowing visitors after hours. Interviews with facility staff, including a licensed nurse and the Director of Nurses, revealed that exceptions should be made to allow family members to visit residents after incidents, especially if the resident is not doing well. The facility's policy on resident rights, dated February 2021, guarantees residents the right to be visited by others from outside the facility. The failure to allow the resident's daughter to visit after the fall incident was a violation of this policy, potentially leading to feelings of isolation, anxiety, and sadness for the resident.
Discrepancy in Tube Feeding Orders for a Resident
Penalty
Summary
The facility failed to ensure that the tube feeding order on the Medication Administration Record (MAR) matched the physician's order for a resident. The resident, who was admitted with diagnoses including diabetes and gastrostomy, was observed to have a tube feeding label indicating Glucerna 1.5 at 50 ml/hr. However, the physician's order specified that the resident should receive Glucerna 1.5 at 60 ml/hr for eight hours, starting at 8 P.M. until 4 A.M. or until the volume order was completed. The MAR for April 2024 showed that the order was not followed as there were no signatures from licensed nurses confirming adherence to the physician's order. Instead, the MAR indicated that the resident received 50 ml/hr for 20 hours, from 12 noon until 8 A.M., which was consistently signed off by the licensed nurses. This discrepancy was noted during a joint interview and record review with the Registered Dietitian (RD) and the Assistant Director of Nursing (ADON). The RD highlighted that the mismatch between the MAR and the physician's order could impact the resident's weight and ability to consume more food by mouth. The ADON acknowledged the discrepancy and stated that physician orders should align with the MAR. The facility did not provide a policy and procedure regarding this issue.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident's rights to be free from sexual abuse when another resident's wandering behavior was not assessed, leading to a non-consensual sexual encounter. Resident 1, who had severe cognitive impairment and required assistance with daily activities, was found in a compromising position with Resident 2, who also had severe cognitive impairment and a history of wandering behavior. Despite staff awareness of Resident 2's wandering and aggressive behaviors, no proper assessment or care plan was in place to address these issues. On the night of the incident, Resident 1 was heard shouting, and a CNA found Resident 2 in Resident 1's bed, engaging in a sexual act. Resident 1 was nonverbal and required hospitalization for evaluation of sexual assault. Interviews with staff revealed that Resident 2 had a history of wandering into other residents' rooms and displaying aggressive behavior, but these behaviors were not properly documented or managed. The facility's policies on resident rights, wandering, and safety and supervision were not followed, as there was no assessment or care plan for Resident 2's wandering behavior. Staff interviews indicated that the incident could have been prevented with proper monitoring and redirection of Resident 2. The facility's failure to implement these measures resulted in a serious breach of resident safety and rights.
Failure to Assess and Plan for Wandering Behavior
Penalty
Summary
The facility failed to assess a resident's wandering behavior and develop a baseline care plan within 48 hours of admission. Resident 2, who had severe cognitive impairment and a history of wandering, was not properly assessed or provided with a care plan to address his wandering behavior. This led to Resident 2 entering other residents' rooms without permission and engaging in inappropriate behavior, including a sexual act with another resident. Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) reported that Resident 2 frequently wandered, asked for his room number, and sometimes became aggressive. Despite these observations, no formal wandering assessment or care plan was created for Resident 2. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not done for Resident 2. The lack of a resident-centered care plan with specific interventions to reduce wandering behavior resulted in Resident 2 entering other residents' rooms, causing distress and potential harm. The facility's failure to follow its own policies on care planning and wandering behavior assessment contributed to this deficiency.
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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 El Centro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Imperial Manor | 4.3 mi | ★★★★★ | 5 | 0 |
| Pioneers Memorial Skilled Nursing Center | 13.3 mi | ★★★★★ | 9 | 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 October 2026) and official state health department websites.