Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Fountain Valley Post Acute during CMS and state inspections, most recent first.
A resident was admitted with documented mycotic toenails and an H&P indicating lack of capacity to make medical decisions. The admission assessment noted mycotic toenails, and a physician ordered daily Kerasal fungal nail renewal solution to both toenails for a set period with reassessment. Facility policy requires a comprehensive, person-centered care plan with measurable objectives, timeframes, and specified services for each identified problem. Despite this, the baseline care plan did not include the ordered treatment or interventions for the mycotic nails. An RN confirmed during interview and record review that the baseline care plan failed to address this condition and acknowledged that all current problems and interventions should have been individualized and included.
Kitchen food safety and sanitation practices were not followed for 130 residents receiving meals from the kitchen. Surveyors observed a cleaning cloth not fully submerged in sanitizer, partially thawed meats without thaw dates, staff with facial hair not properly covered, manual dishwashing done with empty wash/rinse compartments and dishes not fully submerged in sanitizer, frozen foods left open, an unlabeled and undated bin of instant mashed potatoes, and two ice/water dispensers without an air gap.
Failure to obtain informed consent for bed and chair alarms. A resident with no capacity for medical decisions and dependent mobility was observed with a chair alarm attached after staff reported episodes of getting up unassisted. Although the MD ordered the bed pressure pad alarm and wheelchair alarm for fall prevention, the record did not show informed consent from the resident or representative, and the DON acknowledged the consent section was blank.
A resident was observed with an Albuterol Sulfate inhaler on the bedside table and a bag of personal medications at the bedside, and stated he took the medications himself. Although the resident had capacity to make medical decisions, the record did not show a physician order allowing self-administration or bedside storage, and there was no care plan addressing self-administration. An LVN, RN, and the DON verified the lack of authorization and care planning.
Advance directive information and documentation were not ensured for three residents. One resident wanted to redo an existing advance directive, but no copy was placed in the chart; another resident had conflicting AHCD documentation and no copy in the record; and a third resident’s chart noted a family copy would be brought in, but no follow-up was documented and the advance directive was missing from the medical record. The SSD confirmed the missing documentation and lack of follow-up for one resident, while the DON was informed of the findings.
A resident was observed with a chair alarm attached while sitting in a wheelchair, and staff said the resident tried to get up unassisted and was unsteady with a high fall risk. The record showed orders for bed and wheelchair alarms, but there was no documented pre-use assessment for the wheelchair alarm, no documented least restrictive interventions before use, and no documented interventions to address risks related to the restraint. RN and DON interviews confirmed the missing assessment and documentation.
A resident receiving mirtazapine for depression manifested by poor oral intake had inaccurate monthly behavior monitoring tied to the psychotropic medication. The resident’s meal intake record showed less than 50% intake on more occasions than were documented on the psychotherapeutic drug summary sheet, and the ADON verified the mismatch during record review. The DON later verified the findings.
The facility failed to timely and accurately send the Notice of Proposed Transfer/Discharge to the Ombudsman for two residents. One resident’s transfer to acute care had a bed hold order, but the notice was not sent until well after the transfer, and staff acknowledged it was missed on the day of discharge. For another resident transferred to acute rehab at family request, the notice was sent to the wrong Ombudsman email address.
A resident with bilateral nephrostomy tubes had a physician order for tube cleansing and dressing care, but the comprehensive care plan did not include an individualized problem for the nephrostomy tubes. RN verified there was no specific care plan for monitoring the tubes or signs and symptoms of infection, and the DON later verified the finding.
A resident with bilateral nephrostomy tubes was observed with drainage bags attached and reported that the drainage sometimes contained blood. The record showed an order for cleansing and dressing the tube sites, but no physician's order for nephrostomy tube care and monitoring. CNA staff emptied and measured the drainage, and an RN confirmed the missing order; the DON verified the finding.
A resident receiving GT feeding was observed with an enteral formula bottle labeled with another resident’s name. RN and LVN staff verified the incorrect label, and the DON was informed. The resident had an H&P noting he could not make medical decisions by himself, and the order was for Glucerna 1.5 at 45 ml per hour via GT.
Dialysis communication and fluid restriction documentation failures occurred for two residents receiving hemodialysis. One resident’s dialysis center recommendation to check for possible C-diff was not communicated to the MD, and another resident’s 1500 ml fluid restriction was not fully documented because dietary fluid intake was not recorded, even though nursing documented its portion of the order.
Dietary Aide 3 was found not competent in the manual dishwashing procedure despite being documented as competent and attending an in-service on cleaning and sanitizing dishes, utensils, pots, and pans. During a kitchen observation, soiled pans were seen in the wash and rinse sink compartments with no water, and dishes in the sanitizing compartment were not fully submerged. When questioned, the aide described draining the wash and rinse compartments and did not demonstrate the required sink fill levels or sanitizing process.
Menu and recipe preparation were not followed for residents on regular and puree diets. A cook portioned the entree for the lunch meal using a two-ounce scoop even though the cook's spreadsheet listed larger portions, and another cook prepared puree broccoli by adding an unmeasured amount of broth to the blender, resulting in a liquid consistency instead of following the puree recipe. The RD was informed and acknowledged that all recipes should be followed.
Vegetarian Meal Substitute Not Equivalent to Regular Entree: Two residents with a vegetarian meal preference were served tofu with zucchini instead of the regular pork entree, but the substitute provided less protein than the main dish. The DSS said there was no vegetarian menu, and the cook chose from several options without recipes, using the same portion size as the regular menu. The RD confirmed there was no menu, recipes, or cook spreadsheet to ensure the vegetarian alternate matched the nutritive value of the regular entree.
Improper IDDSI Level 6 Food Texture Preparation: The facility failed to prepare meat, vegetables, and bread in the correct Soft and Bite-Sized texture for residents ordered an IDDSI Level 6 diet. During observation, a resident’s meal included meat and vegetables that were minced or finely chopped and a roll that was only partially moistened. In meal prep, staff processed pork, green beans, and broccoli to shredded or minced consistencies, and the DSS stated no IDDSI texture testing was being performed.
Failure to Provide Ordered Adaptive Feeding Equipment: A resident with a weak R extremity was observed eating without the ordered plate guard. Staff were unaware the adaptive feeding device was missing, and record review confirmed a physician order and care plan intervention for the plate guard to be provided during all meals to support self-feeding independence.
Incomplete Facility Assessment: The facility failed to ensure the Facility Assessment included active involvement from required individuals, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. During interview and document review, the Administrator confirmed the assessment lacked documentation of input from direct care staff, resident/family representatives, and did not reflect the updated CMS guidance.
Incomplete POLSTs and inaccurate BP site charting: A facility failed to keep accurate medical records for several residents. Three residents had POLST Section D left blank, while two residents with dialysis access had BP readings documented on the wrong arm in the chart. Staff interviews confirmed the incomplete POLSTs and the inaccurate BP site documentation, and the DON acknowledged the findings.
A resident admitted under hospice care did not have the correct Election of Hospice Benefit Contract in place. Record review showed the signed hospice contract was between Hospice Provider A and a different facility, and MDS staff were unsure about the contract during interview. The DON was informed and acknowledged the discrepancy.
Infection control practices were not maintained when two resident-use washing machines were observed with dust, dirt, and debris around the doors, seals, gaskets, and enclosures, despite routine cleaning expectations. The facility also failed to ensure proper PPE use when a CNA changed a resident on EBP without wearing a gown, even though the room had EBP signage and PPE was available.
The facility failed to complete a change of condition assessment and notify the physician and resident representative when a resident was involved in an abuse allegation. The facility also failed to continuously monitor another resident who had dysuria and was receiving IV antibiotics for a UTI. Records showed the abuse allegation, a care plan addressing psychosocial effects, a change in condition evaluation for painful urination, and an antibiotic order, but documentation did not show the required ongoing monitoring during the resident’s changed condition and antibiotic course.
Call Lights Not Within Reach of Two Residents: Two residents were observed in bed with their call lights out of reach, including one call light hanging far from the resident and another on the floor behind the head of the bed. An LVN and the DON both verified the call lights were not accessible. Both residents had care plans that included keeping the call light within reach, and one resident had severe cognitive impairment while the other had legal blindness.
Failure to Provide Privacy During Wound Treatment: A resident with severely impaired cognitive skills received treatment for a bleeding left forearm skin tear in the activity room while two other residents and staff were present. An LVN cleaned the wound at the table, exposing the resident during the treatment, and both the LVN and DON verified that privacy was not provided and that the resident should have been taken to her room.
Improper Storage of Oxygen Cannula: A resident with an order for oxygen via nasal cannula PRN for SOB had the cannula and tubing observed hanging by the bed and looped around the bed remote control instead of being stored in a clean plastic bag when not in use. The facility P&P required the cannula and tubing to be kept in a plastic bag, and the DON confirmed the proper storage method and acknowledged the finding.
Improper Storage of Internal and External Medications: Surveyors observed bisacodyl suppositories, earwax removal drops, and eye drops stored together in Medication Room A, contrary to the facility’s P&P requiring external and internal medications to be stored separately. An RN confirmed the mix-up risk, and the DON was later informed and acknowledged the finding.
A resident did not receive oxygen therapy as ordered, with the oxygen concentrator set above the prescribed rate and the nasal cannula applied by a CNA instead of a licensed nurse. The nasal cannula was not stored according to infection control policy, and the resident's MDS was inaccurately coded, failing to reflect ongoing oxygen use.
A resident who lacked decision-making capacity experienced an unwitnessed fall, and the required shift-by-shift monitoring for 72 hours post-incident was not documented by licensed nurses as per facility policy. Nursing staff and the DON confirmed the absence of this documentation in the medical record.
A facility failed to report a staff-to-resident abuse allegation in a timely manner, as required by their policy. A resident, unable to make medical decisions but able to communicate needs, reported multiple allegations after an unwitnessed fall, including an accusation against a male CNA. Despite being aware of the incident, the SSD and DON did not ensure the allegation was reported to the appropriate authorities, risking the allegation going unreported and uninvestigated.
A facility failed to investigate an alleged abuse incident involving a resident who reported an unwitnessed fall and injury, claiming a male CNA attacked her. Despite the facility's policy requiring thorough investigation of all abuse allegations, the DON chose not to investigate, citing the resident's fixation on a former employee. This inaction posed a risk of unidentified abuse and unprotected residents.
The facility failed to provide safe respiratory care for several residents, including improper use and storage of CPAP machines, nasal cannulas, and nebulizer masks. Orders for oxygen administration were not followed, and equipment was not stored in a sanitary manner, potentially affecting residents' respiratory health.
The facility did not follow the prescribed menu for residents on pureed diets, as the pureed fresh green salad with dressing was not served to 20 residents. Instead, a V8 juice puree was used as a substitute without prior notification. The FSD and RD confirmed the menu was not followed, and the substitution was not documented in advance. This oversight had the potential to impact the nutritional intake of the residents.
The facility failed to follow food safety and sanitation guidelines, with expired poultry found in the refrigerator and unclean kitchen utensils. The FSD confirmed the expired food needed to be discarded, and utensils were not maintained properly, posing a risk for foodborne illnesses among 132 residents.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident was found with the call light on the floor, needing help to change a wet diaper, while another resident's call light was out of reach on a wheelchair, requiring assistance to cut bread. CNAs confirmed the call lights' locations and provided the necessary help.
A facility failed to conduct a PASARR Level I screening for a readmitted resident with a history of mental health issues, as required by policy. The resident was on medications for schizophrenia and depression, yet the necessary screening to identify potential needs for specialized services was not performed. Staff interviews confirmed the oversight.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. A resident with an indwelling urinary catheter lacked a care plan for EBP, while another resident with an oxygen order had no care plan for its use. A resident on a LAL mattress and another with a midline catheter also lacked appropriate care plans. Additionally, a resident's oxygen therapy was administered at a lower rate than prescribed, indicating a failure to adhere to the care plan.
A resident who required a communication board in Vietnamese to communicate care needs was not provided with one, despite the facility's policy to arrange for such aids. Observations and interviews confirmed the absence of the necessary communication board, which hindered effective communication between the resident and staff.
The facility failed to provide appropriate pressure ulcer care for three residents at high risk for skin breakdown. A resident was found on a LAL mattress with an incorrect pressure setting for her weight, and there was no physician's order for its use. Two other residents were on LAL mattresses without specific directions for settings, lacking physician's orders and care plans. This indicates a failure to provide necessary care and services to promote skin healing and prevent pressure ulcers.
The facility failed to ensure that disposed narcotic count sheets were signed by two licensed nurses, as required by their policy. On a specific date, tramadol and chlordiazepoxide were placed in the narcotic box, but the log was only signed by one nurse. This oversight was confirmed by RN 1 and the DON, highlighting a potential for medication diversion.
The facility failed to ensure two residents were free from unnecessary drugs. One resident was prescribed amitriptyline and bupropion without monitoring target behaviors, and interviews revealed no verbalization of sadness. Another resident was prescribed Zoloft without documented behaviors of sadness or non-pharmacological interventions. The facility's policy required documentation and non-pharmacological interventions, which were not followed.
A facility's medication error rate was found to be 12%, exceeding the acceptable threshold of 5%. This was due to errors by LVNs in administering medications. One LVN failed to instruct a resident to close their eyes for the required time after administering eye drops, while two other LVNs did not check residents' bowel patterns before administering a stool softener, contrary to physician orders.
The facility failed to ensure safe storage and management of medications, with expired drugs found in the Central Supply Room and medication carts, and medications left at residents' bedsides without proper authorization. Unattended and unlocked medication carts were also observed, and medications for discharged residents were not disposed of properly. These deficiencies were confirmed by staff and posed risks for unsafe medication administration.
Two residents did not receive the appropriate mechanically altered diets as ordered by their physicians. One resident was served a regular diet instead of a mechanical soft diet, despite having dysphagia, while another resident did not receive the milk and coffee specified on her diet card. These oversights were confirmed by staff and pose risks to the residents' health.
A resident was not provided with the required assistive eating device during meals, as observed during a lunch observation. The resident used regular utensils despite having a physician's order and care plan intervention for built-up utensils. The facility's policy mandates that such devices be recorded on meal tickets, which was not done in this case. Staff interviews confirmed the oversight.
The facility did not follow its policy on educating staff and visitors about safe food handling for food brought in from outside, risking foodborne illness for residents. Interviews revealed that while general food handling training was provided, specific education on handling outside food was lacking. The DON confirmed the absence of such education despite encouraging families to bring food.
The facility failed to maintain infection control by not implementing Enhanced Barrier Precautions (EBP) for residents with indwelling catheters and midline IVs, as observed in two residents. Staff did not wear PPE during care activities, and there were no EBP signs or supplies outside the residents' rooms. Additionally, the facility did not conduct adequate infection surveillance, failing to include residents with signs of infection not on antimicrobials in reports, and did not document pathogens in infection reports. An indwelling urinary catheter drainage bag was found on the floor in a resident's room, further indicating lapses in infection control.
The facility failed to educate and offer pneumococcal vaccinations to six residents, as per its policies. Five residents did not receive educational materials about the vaccine's risks and benefits, confirmed by the IP and DON. Additionally, one resident's responsible party was not offered the PPSV 23 vaccine following the PCV13, contrary to CDC guidelines. These omissions were verified through medical record reviews and interviews, putting residents at risk for pneumococcal infections.
The facility failed to educate and offer the COVID-19 vaccine to six residents as per its policies. Five residents did not receive educational materials about the vaccine's risks and benefits, confirmed by the IP. Additionally, another resident's responsible party was not offered the seasonal COVID-19 vaccine, despite the resident's capacity to make decisions. These deficiencies were verified through interviews and medical record reviews.
A facility failed to assess a resident for self-administration of medication, as required by its policy. A resident was observed using Vicks vapor rub for headaches without a physician's order or a documented care plan and assessment. A nurse confirmed the absence of these necessary documents, highlighting a deficiency in the facility's adherence to its self-administration policy.
The facility failed to maintain dignity for two residents during meal assistance. Both residents, who were severely cognitively impaired, were assisted with meals by staff who stood at the bedside instead of sitting at eye-level, as required by facility policy. This was confirmed by the staff involved and acknowledged by the facility's administration.
Baseline Care Plan Omission for Mycotic Nail Treatment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission that included treatment and interventions for a resident’s mycotic toenails. The facility’s policy on comprehensive, person-centered care plans requires that each resident have a care plan with measurable objectives, timeframes, and descriptions of services to meet physical, mental, and psychosocial needs, including identification of which professional services are responsible for each element of care. The resident’s admission assessment documented mycotic toenails and bilateral upper extremity skin discoloration, and the H&P noted that the resident lacked capacity to understand and make medical decisions. The physician’s orders included a directive dated 3/26/26 for Kerasal fungal nail renewal solution to be applied daily to both toenails for 14 days with reassessment, specifically to treat the mycotic nails. However, review of the resident’s medical record showed that the baseline care plan did not include the treatment and interventions related to the mycotic nails. During an interview and concurrent record review, an RN confirmed that the baseline care plan failed to address the mycotic nail treatment and stated that the care plan should be individualized and include all current problems and interventions. The DON was informed of and acknowledged these findings.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
Food safety practices were not followed in the kitchen for the 130 residents who received food prepared there. During observations, one cleaning cloth stored in the sanitizing bucket was not fully submerged in the sanitizing solution on two separate occasions. The facility’s diet order tally report showed 130 residents received food prepared in the kitchen. The thawing process for meats was not followed. Four 10-pound portions of partially thawed ground beef and four 5-pound ham portions were observed in a black plastic bin in the walk-in refrigerator without a date showing when they were removed from the freezer to begin thawing. The facility’s policy required defrosting meats to be dated when removed from the freezer. Additional kitchen practices were not followed as observed by surveyors. A dietary aide with facial hair wore a face mask, but the facial hair was not covered; another dietary aide with uncovered facial hair was also observed. During manual dishwashing, soiled pans were found in the wash and rinse sink compartments with no water, and dishes in the sanitizing compartment were not fully submerged. Frozen food items in the walk-in freezer were left open and not sealed, a bin of instant mashed potatoes on a prep table had no label or date, and two ice/water dispensers in resident nourishment rooms had no air gap between the drain and the floor sink flood line.
Failure to Obtain Informed Consent for Bed and Chair Alarms
Penalty
Summary
The facility failed to ensure that Resident 17 was informed of the use of bed and chair alarms and that informed consent was obtained before the alarms were used. The facility’s policy stated that restraints shall only be used upon a physician’s written order and after obtaining consent from the resident and/or representative, and that residents and/or surrogates shall be informed about the potential risks and benefits of restraints, including alternatives. Resident 17 was readmitted to the facility, had an H&P noting the resident could make needs known but had no capacity to make medical decisions, and an MDS showing dependence with mobility. Resident 17 was observed in the wheelchair with a chair alarm attached, and staff stated the resident had episodes of getting up unassisted. The physician ordered the bed pressure pad alarm and wheelchair alarm to alert staff when the resident attempted to rise unassisted. Review of the medical record did not show informed consent for the bed and wheelchair alarm, and RN staff confirmed there was no informed consent prior to use. The DON reviewed the safety device assessment and acknowledged that the consent section was left blank.
Failure to Assess Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to ensure that one of 28 sampled residents, Resident 130, was assessed for self-administration of medications. On 1/5/26, Resident 130 was observed with an Albuterol Sulfate inhaler on top of the bedside table, and there was also a bag containing multiple medication boxes and containers with the resident's name on it. Resident 130 stated the medications were his, that his daughter had brought them from home, and that he took them by himself. Review of the medical record showed Resident 130 was admitted to the facility and had an H&P dated 12/11/25 indicating he had the capacity to make medical decisions. However, the record did not show a physician's order authorizing self-administration of the Albuterol Sulfate inhaler or storage of the medication at the bedside, and there was no care plan addressing self-administration of the inhaler. LVN 5 verified the inhaler was at the bedside and stated the resident could not have the medication there. RN 1 also verified there was no physician's order and no care plan problem addressing self-administration, and the DON later verified these findings.
Advance Directive Information and Documentation Not Ensured
Penalty
Summary
The facility failed to provide information regarding the right to formulate advance directives for three sampled residents and failed to maintain advance directive documentation in the medical record for two of them. Facility policy stated that prior to or upon admission, social services would inquire about written directives, provide written information about the right to refuse or accept treatment and to formulate an advance directive, and maintain copies of any executed advance directives in the medical record. The interdisciplinary team was also expected to review decision-making capacity and document changes in the care plan and medical record. For Resident 83, the record showed the resident stated he had an advance directive in place but wanted to redo it, and a blank copy would be provided. A social history review also documented that no AHCD had been completed and that the SSA offered to complete one, but the resident declined. The medical record did not contain a copy of an advance directive, and the SSA confirmed a blank copy had been provided but no documentation showed the advance directive was completed. For Resident 130, admission documentation stated the resident reported having an advance directive and would ask his daughter to bring a copy, while another note stated no AHCD had been completed and the resident declined. The resident later stated he had an advance directive at home and said the facility asked about it, but he was not asked to bring a copy when admitted. For Resident 13, the record noted the resident had an advance directive and that family would bring a copy, but no copy was found in the medical record and there was no documented follow-up with the family member. The SSD stated she was responsible for explaining advance directives and following up for copies, but verified she did not provide her email address to Resident 13's brother and did not follow up to obtain the document.
Unnecessary use of wheelchair alarm as a restraint
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary physical restraints. Resident 17 was observed in the activity room sitting in a wheelchair with a chair alarm attached to the resident, and activity staff stated the resident had episodes of getting up from the wheelchair unassisted. The resident had been readmitted to the facility and had a care plan for fall risk that included use of a bed pressure pad alarm and wheelchair alarm to alert staff to attempts to rise unassisted. Resident 17’s medical record showed the resident could make needs known but had no capacity to make medical decisions, and a nursing safety device assessment noted weakness and balance deficits contributing to the need for a safety device, with a recommended device of a bed sensor pad. The physician’s order included both a bed pressure pad alarm and a wheelchair alarm for attempts to rise unassisted. However, the record did not show that an assessment for the wheelchair alarm was completed before use, that least restrictive interventions were implemented before the alarms were used, or that interventions to prevent and address risks related to the restraints were developed and implemented. During interviews, CNA 2 and LVN 7 stated the resident used the bed and wheelchair alarms because the resident tried to get out of bed or the wheelchair, was unsteady, and was at high risk for falls. RN 1 stated that prior to use of a physical restraint, the licensed nurse should complete an assessment, implement and document least restrictive interventions, inform the physician, obtain consent, and monitor the resident every shift. RN 1 also verified that an assessment for the wheelchair alarm had not been completed prior to use and that least restrictive interventions and related interventions had not been implemented for Resident 17. The DON was informed and acknowledged the findings.
Inaccurate Monitoring of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary psychotropic medication use when the monthly behavior summary for mirtazapine was not accurately monitored and recorded. Resident 83 had an order for mirtazapine 7.5 mg at bedtime for depression manifested by poor oral intake less than 50%, along with an order to monitor behavior episodes of depression for the use of the medication. Review of the resident’s meal intake record showed less than 50% intake for 65 episodes over a 30-day period, while the Resident Psychotherapeutic Drug Summary Sheet for December 2025 documented only 41 episodes under behavior data. During interview and concurrent record review, the ADON verified that the meal percentage monitoring for the mirtazapine medication was not accurate when compared with the behavior record. The DON was later informed and verified the findings.
Delayed and inaccurate Ombudsman notification for proposed transfers
Penalty
Summary
The facility failed to timely notify and accurately send the Notification of Proposed Transfer/Discharge to the Office of the State Long-Term Care Ombudsman for two residents reviewed in closed record audits. Facility policy stated that residents or their representatives are to be notified in writing of an impending transfer or discharge, and that a copy of the notice is to be sent to the Ombudsman at the same time the notice is provided to the resident and representative. For one resident, the physician ordered transfer to an acute care hospital with a 7-day bed hold, but the Notification of Proposed Transfer/Discharge was not sent to the Ombudsman until more than a month later. A staff member verified that the notice was missed on the day of transfer, and the DON acknowledged the finding. For the second resident, the physician ordered transfer to acute rehabilitation per the family’s request, and although the notice indicated the Ombudsman was notified, the email address used did not match the assigned Ombudsman’s email address for the facility. The SSD and DON were informed and verified the findings.
Failure to Care Plan Nephrostomy Tubes
Penalty
Summary
The facility failed to develop a comprehensive plan of care to reflect the individual care needs for Resident 20, specifically failing to create a care plan problem for the resident's nephrostomy tubes. Resident 20 was admitted to the facility and had the capacity to understand and make decisions. The medical record showed a physician's order dated 12/29/25 to cleanse the right and left nephrostomy tubes with saline, pat dry, and cover with dry dressing. Review of the comprehensive care plans showed no individualized care plan problem addressing Resident 20's nephrostomy tubes. During an interview and concurrent record review on 1/8/26, RN 1 verified that Resident 20 had nephrostomy tubes on both the right and left kidney and confirmed there was no specific care plan for the care and monitoring of signs and symptoms of infection related to the nephrostomy tubes. On 1/12/26, the DON was informed and verified the findings.
Missing Physician Order for Nephrostomy Tube Care
Penalty
Summary
The facility failed to obtain a physician's order for the care and monitoring of Resident 20's nephrostomy tubes. During the initial tour, Resident 20 was observed in bed with a leg drainage bag attached to both thighs and stated that the drainage was from his kidneys and that the drainage bag sometimes had blood. Resident 20's medical record showed he was admitted to the facility and had the capacity to understand and make decisions. Review of the order summary showed a physician's order dated 12/29/25 to cleanse the right and left nephrostomy tube with saline, pat dry, and cover with dry dressing. However, the record did not show a physician's order for the care and monitoring of the nephrostomy tubes. CNA 4 stated she emptied the drainage bags at the end of her shift and as needed, measured the urine output, and reported it to the nurse. RN 1 verified that Resident 20 had nephrostomy tubes on both the right and left kidney and acknowledged there was no physician's order for the care and monitoring of the nephrostomy tube. The DON was informed and verified the findings.
Incorrect Resident Name on Enteral Feeding Bottle
Penalty
Summary
Appropriate GT care and services were not provided for one of two sampled residents reviewed for GT use, Resident 101. During an initial tour, Resident 101 was observed in bed receiving Glucerna 1.5 cal enteral feeding through a GT at 45 ml per hour. The enteral formula bottle was labeled with the name of a different resident. LVN 6 was called to the bedside, observed the bottle, and verified that the GT feeding bottle had an incorrect resident name label. Resident 101 was admitted to the facility and had an H&P examination dated 7/30/25 showing the resident could not make medical decisions by himself. The physician's order summary showed an order dated 1/6/26 for Glucerna 1.5 at 45 ml per hour via GT for a total of 900 ml. During interview and concurrent record review, RN 1 verified that licensed nurses must confirm the physician order, correct formula, and correct resident before enteral feeding administration, and acknowledged the incorrect resident name on the enteral feeding bottle. The DON was also informed and verified the findings.
Dialysis Communication and Fluid Restriction Documentation Failures
Penalty
Summary
The facility failed to ensure dialysis-related instructions were followed for two residents receiving hemodialysis. For Resident 113, who had a BIMS score of 13 and was cognitively intact, the Dialysis Center documented a recommendation to check the resident for possible C-diff and noted that loperamide 4 mg was given at the Dialysis Center. The facility’s LVN verified that this recommendation was not communicated to the facility MD. The facility’s policy on Care of Residents on Hemodialysis stated that the Dialysis Center and facility were to communicate by telephone or dialysis communication papers regarding significant findings and changes in condition. For Resident 10, who had ESRD and no capacity to understand and make decisions, the physician ordered a 1500 ml/24-hour fluid restriction with specific amounts assigned to dietary and nursing. Review of the MAR showed nursing documentation for the 660 ml to be provided by nursing, but the record did not show documented evidence of the 840 ml of fluid to be provided by dietary. CNA 4 stated she reported how much the resident consumed at meals but did not record the amount of fluids, only the meal percentage. RN 1 verified that nursing documented fluids given by nursing and acknowledged that no fluid intake from dietary was recorded.
Dietary aide not competent in manual dishwashing procedure
Penalty
Summary
The facility failed to ensure one of 20 kitchen staff members, Dietary Aide 3, was competent in the manual dishwashing procedure in the food and nutrition department. Review of the facility’s Dietary Aide Competency Checklist signed by Dietary Aide 3 and the DSS on 10/9/25 showed that Dietary Aide 3 was documented as competent in washing and cleaning utensils as directed and in performing dishwashing/cleaning procedures. The facility’s Dietary In-Service on Cleaning and Sanitizing Dishes, Utensils, Pots and Pans dated 11/10/25 also showed Dietary Aide 3 attended the training. During the initial kitchen tour on 1/5/26 at 0855 hours, surveyors observed manual warewashing and interviewed Dietary Aide 3 at the same time. Soiled pans were observed in the wash and rinse sink compartments with no water present, and the third sink compartment had dishes that were not fully submerged in the sanitizing solution. When asked to demonstrate the manual dishwashing procedure, Dietary Aide 3 stated he would use soap with a scrubbing sponge and then rinse the dishes. When asked what the water line labeled on the outside of the wash and rinse sinks meant, Dietary Aide 3 stated it was where the water should be filled up to, and he stated he had drained the water in both the wash and rinse compartments when he started washing the dishes. The DSS confirmed the wash and rinse compartments should be filled with water to the indicator line and that dishes in the sanitizing solution should be fully submerged for one minute.
Menu and Recipe Preparation Not Followed
Penalty
Summary
The facility failed to ensure the menu and recipes were followed for residents on regular and puree diets. During a lunch meal observation, a cook was seen portioning the ground beef for the Southern style patty using a two-ounce scoop, and he stated the portion sizes for the patty were to be two to three ounces, even though the facility document titled Cooks Spreadsheet showed the regular diet should receive four ounces for a regular portion and three ounces for a small portion. The dietary supervisor was present during the initial kitchen tour and the lunch preparation observation was conducted with the cook. The facility also failed to follow the recipe for puree broccoli for residents on the puree diet. The facility document titled Recipe: Pureed (IDDSI Level #4) Vegetables directed staff to measure the total number of portions needed and puree the vegetables to a paste consistency before adding any liquid, then gradually add warm liquid if needed. During observation, a cook was seen preparing broccoli for the puree diets by adding broccoli and an unmeasured amount of vegetable broth to a blender. After blending, the mixture was observed to be a liquid consistency, and the cook stated he would add thickener as he went to get the correct texture. The RD was informed and acknowledged that all recipes should be followed.
Vegetarian Meal Substitute Not Equivalent to Regular Entree
Penalty
Summary
The facility failed to ensure that two residents with a vegetarian meal preference received a vegetarian meal substitute equivalent in nutritive value to the main entree served. On 1/6/26, the facility’s cook spreadsheet showed the regular lunch entree was three ounces of pork with pear sauce, and the facility’s nutritional information showed that portion provided 15.75 grams of protein. The facility’s nutritional information for the vegetarian lunch alternate, three ounces of tofu, showed it provided nine grams of protein. During observation and interviews, the dietary supervisor stated that residents with a vegetarian meal preference were to receive stir fried tofu with zucchini for lunch, but the facility had no menu for vegetarian diets. The cook stated there were several vegetarian options to choose from and that he decided which substitute to serve, using the same portion size as the regular diet on the menu spreadsheet. The RD verified that the vegetarian meal preference was an alternate to the regular diet and confirmed there was no menu, recipes, or cook spreadsheet for the vegetarian meal preference to ensure the substitute was equivalent in nutritive value to the regular menu entree served.
Improper IDDSI Level 6 Food Texture Preparation
Penalty
Summary
The facility failed to ensure that food was prepared in the proper texture for residents ordered an IDDSI Level 6 Soft and Bite-Sized diet. The report states that 12 of 12 residents on this diet were affected, and that the meat, vegetables, and bread were not properly prepared to match the ordered texture. The facility’s own General Preparation Recipe for IDDSI Level 6 directed staff to chop food into 1.5 cm by 1.5 cm pieces, moisten food as needed, and use critical tests and the IDDSI audit to confirm the texture level, but the DSS stated that no testing was currently being performed. During a dining observation, a resident’s lunch included meat with gravy, vegetables, mashed potatoes with gravy, and a roll; the meat and vegetables were observed as minced or finely chopped, and the roll was only partially moistened with the top half appearing dry. During a meal preparation observation, staff prepared pork by blending cooked portions in a food processor to a shredded consistency, then added gravy, and also blended cooked green beans and broccoli to a minced consistency. The RD and ST were informed that the pork, broccoli, and the roll served were not the correct IDDSI Level 6 texture, and both acknowledged that all diets must match the physician’s order.
Failure to Provide Ordered Adaptive Feeding Equipment
Penalty
Summary
The facility failed to ensure that Resident 11 was provided the necessary adaptive eating equipment, specifically a plate guard, as ordered by the physician. During an observation at the bedside, Resident 11 was seen eating from a food tray using the right hand, and the right extremity was observed to be weak. When LVN 5 was asked whether the resident had adaptive equipment for eating, the LVN was not aware and verified that no plate guard was on the resident’s food plate. A follow-up observation later showed Resident 11 still without adaptive equipment in the plate. Medical record review showed a physician’s order dated 1/4/26 for a plate guard during all meals to facilitate independence with self-feeding three times a day, and the care plan included an intervention for adaptive feeding equipment to be provided during all meals. RN 1 confirmed the order existed and stated the adaptive equipment should have been with the food tray for Resident 11 to use. The DON was also informed and acknowledged the findings.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to ensure the Facility Assessment was complete. The report states that the Facility Assessment did not include the active involvement of the required individuals in developing the assessment, including direct care staff, direct care representatives, residents, residents' representatives, and residents' family members. It also did not include a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. The deficiency was identified through interview and facility document review. The Facility Assessment reviewed on 1/15/25 did not show documentation that the required individuals were actively involved in developing the assessment, the staffing recruitment and retention plan, or a contingency plan for staffing needs. On 1/8/26 at 1440 hours, the Administrator confirmed during interview and concurrent document review that the Facility Assessment dated [DATE] had no documentation of direct care staff, direct care representatives, residents' representatives, or family members being actively involved, and no documentation of a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. The Administrator stated he was not aware of the current guidance and acknowledged the Facility Assessment was not updated based on the latest CMS guidance.
Incomplete POLSTs and inaccurate blood pressure site documentation
Penalty
Summary
The facility failed to maintain accurate medical records for five sampled residents. Review of facility policy showed documentation in the medical record was to be objective, complete, and accurate. Surveyors found that the POLST Section D was left incomplete for three residents, and the medical record did not accurately reflect blood pressure access sites for two residents with dialysis access. For Resident 15, Resident 87, and Resident 99, review of their POLST forms showed Section D, which includes Information and Signatures, had blank boxes for Advance Directive, Advance directive not available, or No Advance Directive. During interviews, the MDS 1 stated the SSD was responsible for reviewing the POLST for completion and acknowledged that Section D was incomplete for each of these residents. The SSD later verified that Section D had not been completed for all three residents and stated it should be completed and accurate so the care team could care for the residents appropriately. For Resident 113, who had an AV graft on the left upper arm and a care plan and physician order to avoid blood pressure measurements, venipuncture, injections, and other procedures on the left upper arm, the Weights and Vitals Summary showed multiple blood pressure readings documented on the left arm. The resident stated she never allowed nurses to take her blood pressure on the left upper arm. LVN 3 verified the resident had an AV shunt on the left arm and acknowledged the blood pressure documentation was on the left arm, stating it should not be taken there. For Resident 13, who had an AVF on the right upper arm and a physician order not to take blood pressure, perform needle sticks, or draw blood on the right upper extremity, the Weights and Vitals Summary showed multiple blood pressure readings documented on the right arm. The resident stated nurses checked his blood pressure on the left arm and that he reminded them not to use the right arm. CNA 1 stated she knew not to take blood pressure on the arm with dialysis access, but she usually did not specify which arm was used in the paper vital signs record. LVN 4 verified the resident had a right upper arm AVF and confirmed the right arm documentation in the vitals summary.
Missing Hospice Election Contract
Penalty
Summary
The facility failed to ensure it had the proper hospice contract in place for one resident receiving hospice services. Medical record review showed the resident was admitted under Hospice Provider A with a physician order for routine hospice care, and the resident's Election of Hospice Benefit Contract was dated 12/24/25. However, the signed contract for hospice services was between Facility A and Hospice Provider A, while the resident's Election of Hospice Benefit Contract showed a contract between Hospice Provider A and a different facility. During interview and concurrent record review, MDS 2 was unsure about the hospice election contract and verified the discrepancy. The DON was later informed of the findings and acknowledged them.
Infection Control Lapses in Laundry Machine Cleaning and EBP PPE Use
Penalty
Summary
The facility failed to maintain its infection prevention and control program and practices. During a laundry room inspection, the two washing machines used for residents’ soiled sheets and clothing were observed with dust and dirt accumulation, along with brown to dark brown debris around the doors, door seals, gaskets, and enclosures. The Maintenance Director verified these findings, and the Maintenance Assistant stated the machines received a weekly deep cleaning, while the Housekeeper stated they were wiped with disinfectants at the start and end of the day. The Infection Preventionist was later informed of the condition of the machines and acknowledged that they should be maintained clean and sanitary inside and out to avoid contamination of linens and other resident items. The facility also failed to ensure proper PPE use during care for a resident on Enhanced Barrier Precautions. Resident 40 had a physician’s order for EBP with gowns and gloves required for high-contact care activities related to a left knee incision site, and the resident’s record showed the resident had the capacity to understand and make decisions. Although the room had EBP signage and PPE available, CNA 3 was observed changing the resident without wearing a gown and confirmed she did not use one. The Infection Preventionist verified the resident was on EBP and stated staff needed to use a gown and gloves when performing ADL care for residents on EBP, and the DON was later informed and acknowledged the findings.
Failure to Notify and Monitor Residents With Change in Condition
Penalty
Summary
The facility failed to initiate a change of condition assessment and failed to notify the physician and resident representative when one resident was involved in an allegation of abuse. The facility’s abuse policy stated that all reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are to be reported and investigated, and that the resident’s representative and attending physician are to be immediately notified. The resident involved had capacity to make medical decisions, and the record showed a report of an allegation of physical abuse by another resident. The resident’s care plan addressed psychosocial and emotional effects related to the alleged or suspected abuse from a roommate, but the medical record did not show a change of condition assessment was initiated and did not show notification of the physician or resident representative. For another resident, the facility failed to continuously monitor the resident when the resident had dysuria and was receiving antibiotics for a UTI. The resident stated that at times she had pain when urinating and that she reported it to the nurses, and she also stated she was receiving IV antibiotics daily. The record showed an eINTERACT change in condition evaluation for complaints of pain with urination, with the attending physician notified and a urinalysis and culture ordered. The order summary also showed ceftriaxone sodium 1 gram IV every 24 hours for UTI for seven days. The resident’s record did not show documented evidence that staff continued to monitor the resident after the change in condition and during antibiotic use. A nurse interviewed by surveyors stated that dysuria, UTI, and antibiotic use were changes in condition and that licensed nurses should monitor the resident every shift for at least three days and throughout the course of antibiotics and for three days after completion. The nurse verified that the resident was not continuously monitored every shift when the resident experienced dysuria and while receiving antibiotics, and the DON acknowledged the finding.
Call Lights Not Kept Within Reach of Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the needs and preferences of two residents by not keeping their call lights within reach. The facility’s policy titled "Answering the Call Light" stated that when a resident is in bed or confined to a chair, the call light should be within easy reach of the resident. Resident 87 was observed lying in bed with the call light hanging on the left side of the bed, far from the resident. During the observation, Resident 87 attempted to reach for the call light and stated she was unable to see it or reach it. An LVN later observed the same condition and verified the call light was not within the resident’s reach. Resident 87’s record showed no capacity to understand and make decisions, a BIMS score of 2 indicating severe cognitive impairment, and a care plan intervention to keep the call light within reach. Resident 99 was observed lying in bed with the call light on the floor behind the head of the bed. The DON observed this condition and verified the call light was not within the resident’s reach. Resident 99’s record showed no capacity to understand and make decisions and a care plan intervention to keep the call light within reach due to impaired vision as evidenced by legal blindness.
Failure to Provide Privacy During Wound Treatment
Penalty
Summary
The facility failed to ensure privacy was provided for one of 28 final sampled residents, Resident 2, during wound treatment. The facility's Resident Rights policy, revised 1/2025, stated employees shall treat residents with kindness, respect, and dignity, and that residents have the right to privacy and confidentiality. Resident 2 was admitted to the facility and had an MDS assessment showing severely impaired cognitive skills for daily decision making. Resident 2 had a physician's order dated 1/12/26 to cleanse a left forearm skin tear with normal saline, pat dry, apply triple antibiotic ointment, and cover with a dry dressing every day for 14 days. On 1/12/26 at 1004 hours, Resident 2 was observed sitting in a wheelchair in the activity room with two other residents and staff at the table, and the left forearm skin tear was bleeding. At 1013 hours, LVN 1 was observed bringing treatment supplies to the activity room, putting on gloves, and cleaning the skin tear while Resident 2 was exposed to facility staff and residents in the activity room. LVN 1 verified privacy was not provided and stated Resident 2 should have been taken to her room for the treatment. The DON also verified Resident 2 was not provided complete privacy during the skin tear treatment and stated the resident should have been in her room to ensure privacy was protected.
Improper Storage of Oxygen Cannula
Penalty
Summary
Resident 150 had an order dated 12/31/25 for oxygen at 4 LPM via nasal cannula as needed for shortness of breath. The resident’s medical record showed a history of capacity to understand and make medical decisions, and the resident stated on 1/6/26 that she uses oxygen intermittently for shortness of breath. During an observation on 1/5/26, the resident’s nasal cannula attached to oxygen tubing was seen hanging by the right side of the bed and looped around the bed remote control instead of being stored in a clean plastic bag when not in use. The facility’s P&P titled Departmental Respiratory Therapy Prevention of Infection, reviewed in 1/2025, stated to keep the oxygen cannula and tubing used as needed in a plastic bag when not in use. The DON was informed of the observation and stated the cannula should be stored in a clean plastic bag to prevent infection and that if it was not stored in a bag, it could be exposed to bacteria and cause respiratory infection. The DON later acknowledged and verified the findings.
Improper Storage of Internal and External Medications
Penalty
Summary
The facility failed to ensure medications in Medication Room A were stored properly and separately as required by its Medication Labelling and Storage policy. During an inspection on 1/6/26, surveyors observed 10 boxes of bisacodyl suppositories, 10 boxes of earwax removal drops, and 3 boxes of eye drops all stored together in the medication room. RN 1 confirmed the observation and stated that external and internal medications needed to be separated and not stored together to prevent accidental mix up of the medications. The DON was later informed of the findings and acknowledged them on 1/13/26.
Failure to Ensure Proper Oxygen Administration and Accurate Documentation
Penalty
Summary
The facility failed to ensure that a resident received appropriate respiratory care as ordered by the physician. Specifically, the resident had a physician's order for oxygen via nasal cannula at 2 LPM every shift, with instructions to notify the physician if oxygen saturation dropped below 88%. However, observations revealed that the oxygen concentrator was set at 2.5 LPM, not the ordered 2 LPM. Additionally, a CNA applied the nasal cannula to the resident instead of a licensed nurse, contrary to facility policy and staff statements that only licensed nurses should administer oxygen to ensure correct settings. The nasal cannula was also not stored in an oxygen storage bag as required for infection control. Further review showed that the resident's Minimum Data Set (MDS) was not accurately coded to reflect that the resident was on continuous oxygen therapy, despite documentation and staff verification that the resident was receiving oxygen. Oxygen saturation readings were recorded as being taken on room air on multiple occasions, which did not align with the physician's order for continuous oxygen. These findings were confirmed through interviews with the CNA, LVN, and DON, as well as review of the resident's medical record and facility policies.
Failure to Document Post-Fall Monitoring for a Resident
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete following a fall incident. Specifically, after an unwitnessed fall with no evidence of injury, the required documentation of the resident's condition monitoring every shift for 72 hours was not completed. The facility's policy required licensed nurses to record information related to changes in a resident's condition and to continue monitoring and documenting the resident's status every shift for 72 hours after such an event. However, a review of the resident's progress notes revealed missing documentation for several shifts during the required monitoring period. Interviews with nursing staff confirmed that the expectation was to assess and document the resident's condition every shift for 72 hours post-fall. Both RN 3 and RN 4 acknowledged that the necessary documentation was not present in the medical record, and the DON verified these findings. The resident involved had no capacity to understand or make decisions, as noted in their medical history, further emphasizing the importance of thorough monitoring and documentation after the fall.
Failure to Report Abuse Allegation in a Timely Manner
Penalty
Summary
The facility failed to implement its abuse policy and procedures by not reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. Specifically, the facility did not report in a timely manner an allegation of staff-to-resident abuse involving a resident who had an unwitnessed fall resulting in injury. The resident, who was unable to make medical decisions but could communicate needs, reported multiple allegations regarding the cause of the fall, including an accusation that a male CNA attacked her. Despite these allegations, there was no documented evidence that the abuse allegation was reported to the local State and Federal agencies as required by the facility's policy. Interviews with facility staff, including the Social Services Director (SSD) and the Director of Nursing (DON), confirmed that they were aware of the incident and acknowledged that the allegation should have been reported as abuse. The SSD, a mandated reporter, verified the incident occurred and should have been reported, while the DON was made aware of the allegation on the day it occurred but did not ensure it was reported. This failure to report the abuse allegation in a timely manner had the potential for the abuse allegation to go unreported and uninvestigated.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policy and procedure (P&P) related to the investigation of physical abuse for one resident. The facility's P&P requires that any incident or allegation of abuse be thoroughly investigated by the administrator, with specific steps including reviewing documentation, interviewing involved parties, and submitting a report to the State Survey Agency within five working days. However, in the case of one resident, this protocol was not followed. The Director of Nursing (DON) was aware of the resident's allegation of abuse but decided not to investigate, citing the resident's fixation on a male CNA who no longer worked at the facility. The resident in question had an unwitnessed fall resulting in injury and reported three different allegations regarding the incident, including an attack by a male CNA. Despite the facility's protocol requiring an investigation of all abuse allegations, the DON acknowledged that no investigation was conducted. This failure to investigate posed a risk for potential abuse to remain unidentified and for residents to go unprotected.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies observed during a survey. Resident 793's physician's order for the use of a CPAP machine was not followed, and the resident was not utilizing the CPAP machine as ordered. Additionally, the resident's nasal cannula was not stored in a sanitary manner. The medical record review revealed that there was no follow-up regarding obtaining the CPAP machine, and the physician was not notified about the resident not using the CPAP machine. Resident 5's nasal cannula was not changed according to facility procedures, and the nebulizer mask storage bag was not labeled per facility policy. Resident 57's CPAP and nebulizer mask were not stored in a sanitary manner when not in use, and Resident 72's nebulizer mask was also not stored properly. Resident 595's oxygen tubing was not labeled or stored in a respiratory bag, and there was no signage indicating oxygen in use outside the resident's room. Resident 43 was not administered continuous oxygen as per the physician's order, and Resident 110's nasal cannula was found lying on the floor. The facility also failed to administer oxygen as per the physician's order to Resident 68 and did not change the nasal cannula oxygen tubing weekly. Resident 63 did not have a storage bag for the oxygen, and the storage bag for the nebulizer was not labeled and dated as per the facility's policy. These failures had the potential to affect the respiratory health and well-being of the residents in the facility, as they did not adhere to the facility's policies and procedures for respiratory care and infection prevention.
Failure to Follow Prescribed Menu for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on pureed diets, as observed during a survey. Specifically, the pureed fresh green salad with dressing was not served to 20 residents, including two residents whose lunch trays were missing this item. Instead, a V8 juice puree was used as a substitute without prior notification to the residents. The facility's Food Service Director (FSD) and Registered Dietitian (RD) confirmed that the menu was not followed, and the substitution was not documented in advance as required by the facility's policies. The deficiency was further highlighted by the fact that the pureed fresh green salad was not prepared due to a lack of stock and issues with the blending process. The FSD and RD acknowledged that the V8 juice was not part of the original menu and that the menu had not been updated to reflect this change. Additionally, the residents' medical records indicated a preference for salad, which was not honored due to the substitution. This oversight had the potential to impact the nutritional intake of the residents on pureed diets.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by the presence of expired food items in the kitchen. Specifically, two bins containing thawed poultry were observed in the walk-in refrigerator with use-by dates that had already passed. The Food Service Director (FSD) confirmed that the turkey was supposed to be used the day prior but was not, and both the turkey and chicken needed to be discarded. This oversight posed a risk for foodborne illnesses among the 132 residents who received food prepared in the facility's kitchen. Additionally, the facility did not ensure that kitchen utensils were maintained in a clean and usable condition. Observations revealed a melted and heavily used rubber spatula, a chipped rubber spatula, and a melted handle of a metal spatula stored in the kitchen. Furthermore, a ladle with brown residues was found stored with other clean utensils. These findings were verified by the FSD, indicating a failure to comply with the USDA Food Code requirements for maintaining food-contact surfaces and utensils in a safe and sanitary condition.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, which could potentially delay the residents from receiving timely care. Resident 394 was found awake with his call light on the floor, unable to call for assistance. He expressed the need for help to change his wet diaper. CNA 7 confirmed the call light was on the floor and assisted the resident. Similarly, Resident 132 was observed searching for her call light, which was out of reach on a wheelchair next to her bed. She needed assistance to cut her toasted bread. CNA 4 acknowledged the call light's location and verified the situation.
Failure to Conduct PASARR Screening for Readmitted Resident
Penalty
Summary
The facility failed to ensure that a resident, who was readmitted, had a Level 1 PASARR screening. This screening is crucial for identifying individuals with mental disorders, intellectual disabilities, or related disorders, and determining if they require further evaluation or specialized services. The facility's policy mandates that all individuals be screened per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. However, upon review, it was found that the resident's medical record lacked evidence of a PASARR Level I screening upon their readmission. The resident in question had a history of mental health issues, as indicated by physician orders for medications such as Risperdal for schizophrenia and Trazodone and Escitalopram for depression. Despite these indicators, the PASARR screening was not conducted upon the resident's readmission. Interviews with facility staff confirmed that the screening was overlooked, and it was acknowledged that a PASARR Level I screening should have been completed at the time of readmission.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. Resident 34, who had an indwelling urinary catheter, did not have a care plan developed for evidence-based practice (EBP) despite having physician orders related to catheter management. This oversight was confirmed by an LVN who acknowledged the absence of a care plan for EBP, which was expected for residents with indwelling catheters. Resident 63, who lacked the capacity to make decisions, had a physician order for oxygen administration, but no care plan was developed to address this need. An LVN verified the absence of a care plan for oxygen use, which should have included interventions and goals for maintaining the resident's oxygen saturation levels. Similarly, Resident 76, who was observed lying on a low air loss (LAL) mattress, did not have a care plan for its use, as confirmed by another LVN. Resident 743, who had a midline catheter, also lacked a care plan for EBP, despite having physician orders for monitoring and maintaining the IV site. An LVN confirmed the absence of a care plan for EBP, which was expected for residents with midline catheters. Additionally, Resident 43's care plan for continuous oxygen therapy was not implemented correctly, as the resident received oxygen at a lower rate than prescribed. This discrepancy was verified by an LVN, highlighting a failure to adhere to the care plan for respiratory management.
Failure to Provide Communication Board in Resident's Language
Penalty
Summary
The facility failed to provide a communication board in the resident's language, which was necessary for effective communication of care needs. Resident 60, who was capable of understanding and making decisions, required a communication board in Vietnamese to communicate with the facility staff. Despite the facility's policy to arrange for interpreters or alternate means of communication, such as communication boards, there was no Vietnamese communication board available for Resident 60. During observations and interviews, it was confirmed that Resident 60 did not have access to a communication board in their language. The CNA was observed using hand gestures to communicate, which led Resident 60 to ask the surveyor in Vietnamese about the CNA's intentions. Both the DON and LVN verified the absence of a Vietnamese communication board, acknowledging that it should have been provided to facilitate communication between Resident 60 and the staff.
Inappropriate Use of Low Air Loss Mattresses for Residents
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents at high risk for skin breakdown. Resident 76 was found lying on a low air loss (LAL) mattress with a pressure setting inappropriate for her weight, as the setting was between 660 to 750 pounds, while the resident weighed 285.3 pounds. The Director of Nursing (DON) adjusted the setting to 290 pounds after verifying the resident's weight. Additionally, there was no physician's order for the use of the LAL mattress for Resident 76, which is required by the facility's policy. For Residents 43 and 62, the facility failed to ensure the use of LAL mattresses with specific directions for settings. Resident 43 was observed on a LAL mattress without a physician's order or a care plan specifying the appropriate settings. Similarly, Resident 62, who was at risk for skin breakdown, was on a LAL mattress without a physician's order for its use and settings. The lack of specific orders and care plans for the LAL mattresses for these residents indicates a failure to provide necessary care and services to promote skin healing and prevent pressure ulcers.
Failure to Ensure Dual Signatures on Narcotic Disposal Logs
Penalty
Summary
The facility failed to ensure that the disposed narcotic count sheets were signed by two licensed nurses, as required by their policy and procedure for discarding and destroying controlled medications. During an interview and document review, it was found that on a specific date, 30 pieces of tramadol, nine pieces of tramadol, and 30 pieces of chlordiazepoxide were placed inside the narcotic box, but the Controlled Drugs Log was only signed by one licensed nurse. This oversight was confirmed by RN 1, who acknowledged the discrepancy in the signing process. Further verification by the Director of Nursing (DON) confirmed that the Controlled Drugs Log should have been signed by both an RN and another licensed nurse. The DON stated that the pharmacy consultant and RN are responsible for collecting the controlled medications from the narcotic box for destruction. The failure to have two signatures on the narcotic count sheets had the potential for medication diversion, as it did not comply with the facility's policy and procedure, which is designed to prevent such occurrences.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs, as observed through a combination of interviews, medical record reviews, and policy reviews. Resident 29 was prescribed amitriptyline and bupropion hydrochloride for depression and smoking cessation, respectively. However, the facility did not identify specific target behaviors to monitor for these medications, nor did they document any episodes of the behaviors that these medications were intended to address. Interviews with the Director of Nursing (DON), a Licensed Vocational Nurse (LVN), and a Certified Nursing Assistant (CNA) revealed that Resident 29 had not verbalized sadness or depression, which were the stated reasons for the prescriptions. For Resident 38, the facility did not document specific behaviors of sadness before prescribing Zoloft, nor did they implement non-pharmacological interventions prior to or during the use of the medication. The facility's policy required the identification and documentation of medical symptoms that warrant the use of psychotropic medications, as well as the implementation of non-pharmacological interventions. An interview with the Assistant Director of Nursing (ADON) confirmed the lack of documentation and non-pharmacological interventions for Resident 38.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 12%. This deficiency was identified through several incidents involving Licensed Vocational Nurses (LVNs) and their administration of medications. LVN 2 did not instruct Resident 22 to close their eyes for the required one to two minutes after administering Systane eye drops, as per the facility's policy and procedure (P&P). This oversight was confirmed during an interview with LVN 2, who acknowledged the deviation from the prescribed method. Additionally, LVN 4 and LVN 1 failed to adhere to the facility's P&P regarding the administration of docusate sodium, a stool softener. Both LVNs did not check the bowel patterns of Residents 12 and 97, respectively, for loose stools before administering the medication, despite physician orders to hold the medication in such cases. These lapses were confirmed through interviews and medical record reviews, where both LVNs acknowledged their failure to verify the residents' bowel conditions prior to medication administration.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and management of medications and supplies, as observed in multiple areas. In the Central Supply Room, expired medications and supplies were found, including acetaminophen, fish oil, antifungal creams, and moisturizing lotions without manufacturing or expiration dates. Medication carts were also found to contain expired medications, such as antifungal creams and aspirin without expiration dates, and medications belonging to discharged residents. Additionally, medication carts were left unlocked and unattended, posing a risk for unauthorized access. Several residents were directly affected by these deficiencies. For instance, an antifungal cream was found at the bedside of a resident with severe cognitive impairment, who was not a candidate for self-administration of medications and had no physician's order for the cream. Another resident had A&D ointment left at their bedside, which staff confirmed should not have been there. Furthermore, medications for residents who had been discharged were not disposed of properly, including controlled substances that should have been destroyed or returned to the pharmacy. The facility's policies and procedures for medication storage were not followed, as evidenced by the presence of expired and improperly stored medications. The Director of Nursing and other staff members verified these findings during interviews and observations. The failure to adhere to these policies resulted in the potential for unsafe administration of medications and compromised the safety and sanitary conditions of medication storage areas.
Failure to Provide Physician-Ordered Diets
Penalty
Summary
The facility failed to ensure that two nonsampled residents received the appropriate mechanically altered diets as ordered by their physicians. Resident 14 was observed to be served a regular texture diet instead of the prescribed mechanical soft diet, which was confirmed by the speech therapist and the food service director. The medical records indicated that Resident 14 had a physician's order for a regular diet with mechanical soft texture due to dysphagia, a condition that makes swallowing difficult. Despite this, the resident was not provided the correct diet, posing a risk of aspiration and unmet nutritional needs. Similarly, Resident 132 was not served the milk and coffee as ordered on her diet card. During breakfast, Resident 132 reported that she was served cereal without the accompanying milk and coffee, which was confirmed by a CNA. The diet card for Resident 132 specified the provision of 4 ounces of low-fat milk and black coffee, which were not provided. This oversight in meal service indicates a failure in the facility's food and nutrition services to adhere to physician-ordered diets.
Failure to Provide Assistive Eating Device
Penalty
Summary
The facility failed to provide a nonsampled resident, identified as Resident 53, with an assistive eating device during mealtimes, as required by the facility's policy and the resident's care plan. During a lunch observation, Resident 53 was seen feeding himself using regular utensils with his right hand, without the built-up utensils that were ordered by a physician on 5/16/24 and documented in the resident's care plan initiated on 4/23/24. The meal ticket for Resident 53 did not indicate the need for built-up utensils, contrary to the facility's policy that such devices should be recorded on tray cards and diet profiles. An interview with RNA 1 confirmed the use of regular utensils, and the Food Service Director (FSD) acknowledged the findings.
Failure to Educate on Safe Food Handling for Outside Food
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the safe handling of food brought in by family and visitors for residents. The policy, revised in March 2022, required family and visitors to be educated on safe food handling practices, including safe cooling, reheating, and preventing cross-contamination. However, the facility did not ensure that staff responsible for handling such food, or the family and visitors themselves, were educated on these practices. This oversight posed a risk of foodborne illness to residents consuming food from outside sources. Interviews with facility staff revealed gaps in the implementation of the policy. A CNA described her process for handling outside food, which included cooling hot food before refrigeration, but there was no mention of formal training on safe food handling. The Food Service Director (FSD) and Director of Staff Development (DSD) confirmed that while in-services were provided to kitchen and floor staff regarding general food handling, no specific education was given to staff or family/visitors about handling food brought in from outside. The Director of Nursing (DON) acknowledged the lack of education provided to family and visitors, despite encouraging them to bring food for residents, as long as it complied with therapeutic diets.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain infection control as evidenced by several deficiencies related to the implementation of Enhanced Barrier Precautions (EBP) and infection surveillance. Residents with indwelling urinary catheters and midline IV catheters, such as Residents 34 and 743, were not placed on EBP as per the facility's policies and procedures. Observations revealed that there were no EBP signs or personal protective equipment (PPE) supplies outside their rooms, and staff did not wear PPE when performing care activities that required close contact. Interviews with staff confirmed the lack of adherence to EBP protocols, which are crucial for preventing the transmission of infectious diseases. The facility also failed to conduct adequate surveillance of infections among residents who exhibited signs and symptoms of infection but were not on antimicrobials. The Infection Preventionist (IP) acknowledged that these residents were not included in the surveillance report, which hindered the ability to track and monitor potential infections. Additionally, the facility's Monthly Infection Surveillance Reports for September and October 2024 did not document the organisms or pathogens involved in infections, contrary to the facility's policy. This omission prevented the identification of patterns or clusters of infections and impeded efforts to manage antimicrobial use effectively. Furthermore, the facility did not maintain proper infection control practices in Resident 38's room, where an indwelling urinary catheter drainage bag was found on the floor, and a urinal with urine was hanging from a trash can. These observations were verified by a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) acknowledged the findings. These lapses in infection control practices put residents at increased risk of infection and disease transmission.
Failure to Educate and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that six residents were educated and offered the pneumococcal vaccination as per the facility's policies and procedures. Specifically, the facility did not provide educational materials regarding the risks and benefits of the pneumococcal vaccine to five residents. This omission was confirmed during interviews with the Infection Preventionist (IP) and the Director of Nursing (DON), who acknowledged that the Vaccine Information Statement (VIS) should have been provided to the residents to inform them about the vaccine's risks, benefits, and possible reactions. Additionally, the facility did not offer the PPSV 23 vaccine to the responsible party of one resident who had previously received the PCV13 vaccine, as recommended by the CDC guidelines. This oversight was verified during a medical record review and interview with the IP. These failures put the residents at risk for infection and transmission of pneumococcal infections, as the facility did not adhere to its own policies regarding vaccination education and administration.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that six residents were educated and offered the COVID-19 vaccination as per the facility's policies and procedures. Specifically, the facility did not provide educational materials outlining the risks and benefits of the COVID-19 vaccine to five residents. This omission was confirmed during interviews and medical record reviews, where it was noted that the Vaccine Information Statement (VIS) for COVID-19, which provides detailed information about the vaccine, was not given to these residents. The Infection Preventionist (IP) acknowledged that the educational materials should have been provided to the residents to inform them about the vaccine's risks, benefits, and potential side effects. Additionally, the facility failed to offer the seasonal COVID-19 vaccine to the responsible party of another resident, despite the resident having the capacity to understand and make decisions. The resident's immunization record showed that the last COVID-19 vaccine was administered over two years ago, yet there was no evidence in the medical record that the seasonal vaccine was offered. This oversight was also confirmed by the IP during an interview and medical record review.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medications and had an appropriate order and care plan in place before self-administering medication. The facility's policy and procedure for self-administration of medications, dated February 2021, requires an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration is safe and clinically appropriate. During an observation on November 4, 2024, a blue jar of Vicks vapor rub was seen on the overbed table of a resident, who applied it to her head for headaches. The resident did not have a physician's order for the use of Vicks vapor rub, nor was there a care plan or self-administration assessment documented. A registered nurse confirmed these findings, indicating a lapse in following the facility's policy.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote dignity and respect for two residents during meal assistance. For Resident 103, who was severely cognitively impaired with a BIMS score of 00, the CNA was observed standing at the bedside while assisting with meals, contrary to the facility's policy that requires staff to be seated at eye-level with residents. This observation was confirmed by the CNA, who acknowledged that staff should be sitting down to ensure they are at the same level as the resident. Similarly, for Resident 116, who also had a BIMS score of 00 indicating severe cognitive impairment, the LVN was observed standing while assisting with meals. The LVN confirmed that she should have been seated to maintain the resident's dignity. The facility's policy on meal assistance emphasizes the importance of not standing over residents during meal assistance to ensure their comfort and dignity. The Administrator, DON, and Regional Quality Assurance Nurse acknowledged these findings during an interview.
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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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Nursing homes near Fountain Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Coast Global Medical Center D/p Snf | 2.3 mi | ★★★★★ | 25 | 0 |
| South Coast Post Acute | 2.9 mi | ★★★★★ | 4 | 0 |
| Plaza Healthcare Center | 2.9 mi | ★★★★★ | 10 | 0 |
| Huntington Valley Healthcare Center | 3 mi | ★★★★★ | 8 | 0 |
| Pacific Haven Subacute And Healthcare Center | 3.6 mi | ★★★★★ | 3 | 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 June 2026) and official state health department websites.