Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 El Centro Post-acute Care during CMS and state inspections, most recent first.
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.
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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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 0 | 0 |
| Pioneers Memorial Skilled Nursing Center | 13.3 mi | ★★★★★ | 9 | 0 |
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