Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Freedom Village Healthcare Center during CMS and state inspections, most recent first.
Kitchen sanitation and food storage deficiencies: Surveyors found unlabeled and expired resident food in the refrigerator used for items brought in by visitors, along with dirty lower bins. They also observed dirt inside the ice machine, debris in the plate conveyor, and a wet bin containing scoops that had not been air-dried. The CDM/Executive Chef, Dietary Team Lead, and Maintenance Staff verified the findings.
Two residents were observed with medications at the bedside and taking them on their own, but both had self-administration assessments showing they were not safe candidates for self-administration. One resident had Renvela left in a medication cup and the other had a nasal spray bottle at the bedside; neither record contained a physician order for self-administration, and neither care plan addressed self-administration. The DON verified the findings.
Call Light Not Visible or Within Resident Reach: A resident with no capacity to make medical decisions and moderately impaired cognition was found in bed unable to locate the call light while wanting to use the bathroom. Staff later found the call light covered by bedding near the resident's thigh, and both a CNA and an LVN acknowledged it was not visible or within reach as required by facility policy.
Failure to Timely Report Abuse Allegation: A resident alleged that a staff member spoke to her in a rude and disrespectful manner and physically knocked her hand away. The DON stated the allegation of abuse should have been reported within two hours to CDPH, the LTC Ombudsman, and local law enforcement, but the Administrator did not report it because the resident later denied it during the facility’s internal investigation. The SOC 341 was not sent to CDPH until about two and a half days after the facility learned of the allegation.
A resident with moderately impaired cognition and ADL dependence alleged that a staff member spoke to her rudely, made demeaning comments, and physically knocked her hand away. The record did not show physician notification, a change-in-condition evaluation, or monitoring after the facility learned of the abuse allegation, and the DON confirmed the documentation was missing.
Unsafe Water Temperatures in Resident Rooms: The facility failed to keep resident room and sink water temperatures at or below 120 degrees F. During observation, water measured 129 degrees F in one room and 125 degrees F in another, and a log review showed 12 of 27 rooms had sink water temperatures between 122 and 126 degrees F. A resident who was cognitively intact reported that the sink water got too hot on two occasions and she had to add cold water.
A resident was observed receiving oxygen at 2 L/min via NC despite a physician order for 3 L/min continuous oxygen, and an LVN increased the flow after verifying the discrepancy. Another resident's oxygen tubing was observed unlabeled and undated while receiving oxygen at 4 L/min via NC, despite facility P&P requiring tubing to be labeled and changed weekly. The DON and RN acknowledged the findings.
Medication Administration Errors With Breakfast Dosing: An LPN was observed making two medication errors while giving meds to two residents. One resident received ferrous sulfate after breakfast instead of with breakfast as ordered, and another resident received metformin after breakfast instead of with breakfast as ordered. The DON verified both errors, and the facility’s medication error rate was 8%.
Medication storage and labeling were deficient when a tube of Silicone Cream was found on a resident's sink counter without an order, and oral and non-oral meds were stored together in the med room. The med refrigerator was dirty, and boxes of enteral feeding formulas and IV supplies were stored on the floor in the supply room. An RN, LVN, Administrator, and DON acknowledged the findings.
The facility failed to maintain an infection control program with complete surveillance documentation and proper EBP implementation. The infection surveillance report listed total infections, CAI, and HAI counts, but did not identify whether residents met McGeer criteria or whether each case was HAI, CAI, or suspected infection. A resident with a left lower extremity post-biopsy wound had an order for EBP, but staff observed no EBP sign or PPE cart at the room, a CNA reported not being told the resident was on EBP, and an LVN entered the room without performing hand hygiene.
Failure to Monitor Antibiotic Use for Residents Without Evidence of True Infection: Two residents received antibiotics despite surveillance and screening records not showing signs and symptoms that met McGeer’s criteria for true infection. One resident was on doxycycline after abdominal surgery and wound debridement, and the other was on vancomycin HCL for recurrent C. difficile prophylaxis; records did not show physician follow-up or documentation that the infections met criteria for true infection.
Missing vaccine education and documentation: The facility failed to document that residents and/or their representatives were informed of the risks and benefits of influenza and pneumococcal vaccines before refusals were recorded. Several residents had pneumococcal vaccine declinations in the chart without evidence of education, two residents had no documentation that the vaccine was offered or explained, and one resident’s flu vaccine refusal by a representative also lacked documented risk/benefit education. The DSD/IP verified the missing documentation, and the DON was informed.
Failure to Offer COVID-19 Seasonal Vaccine to Two Residents: The facility did not offer the COVID-19 seasonal vaccine to two sampled residents. One resident could make own medical needs known, while the other had no capacity to make medical decisions. CAIR2 and the medical records did not show the updated vaccine was offered, and the IP/DSD verified the facility had not offered it; the DON acknowledged the findings.
Residents were not informed how to contact the local State agency during a residents’ council meeting. Seven residents stated they did not know how to file a complaint directly, and the Activities Director said she only showed the Ombudsman poster and assumed the Ombudsman office could provide the State agency contact information. The residents involved were documented as having the capacity to understand and make decisions or being able to make their needs known.
A resident was transferred to an acute care hospital, and the discharge notice indicated a copy was sent to the LTC Ombudsman. However, the SSD could not produce any email showing the notification was sent, and the LTC Ombudsman confirmed she did not receive notice of the resident’s transfer/discharge.
Two residents had inaccurate skilled nursing respiratory assessments because nebulizer treatment documented on the MAR was not reflected in the charting. Both residents had physician orders for Ipratropium-Albuterol via nebulizer for SOB/wheezing, and the ADON/MRD and DON acknowledged the assessments should have documented the treatment accurately.
A resident experienced significant weight loss and the RD recommended nutritional interventions, but there was a nine-day delay in communicating these recommendations to the physician, resulting in a delay in implementing necessary care. Facility staff acknowledged the failure to relay the RD's recommendations in a timely manner.
A resident's medical record inaccurately documented their fall history, indicating no falls in the last six months despite evidence of a fall prior to admission. This discrepancy was confirmed by an LVN and the ADON, who noted that such inaccuracies could lead to misinterpretation and delay in services, posing a risk to the resident's care.
A resident reported an allegation of physical abuse against two CNAs. Despite the facility's policy requiring suspension of staff accused of abuse, the CNAs continued to work during the investigation period, although they were not assigned to the resident. The DON acknowledged that the CNAs should have been suspended to ensure resident safety.
A facility failed to monitor a resident's safety and psychosocial well-being or develop a care plan after the resident reported an abuse allegation involving two CNAs. The resident alleged rough handling and inappropriate behavior by the CNAs. The facility did not conduct the required 72-hour monitoring or establish a care plan to address the resident's needs, as confirmed by interviews with the RN and DON.
The facility failed to ensure food safety and sanitation in the kitchen, risking food-borne illnesses for 42 residents. Observations included unsanitary kitchen utensils, improper glove use by a dietary aide, and a juice machine lacking an air gap for backflow prevention. These issues were acknowledged by facility leadership.
A resident with impaired mobility and requiring maximal assistance for transfers was injured when a CNA transferred them alone, contrary to the care plan. The resident's leg was caught during the transfer, resulting in a right ankle fracture. The CNA was unaware of the two-person assist requirement, and it was noted that other staff had also been assisting the resident without additional help.
A resident was found with Voltaren gel at their bedside without a physician's order or care plan for self-administration, contrary to facility policy. The resident was applying the gel independently, despite not being assessed as a candidate for safe self-administration. An RN confirmed the lack of necessary documentation and orders.
The facility failed to document and update advance directives for three residents, risking treatment against their wishes. A resident's advance directive was not placed in the medical record, another's was not followed up on, and a third's POLST was not updated to reflect a formulated directive.
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNOC) after the termination of Medicare Part A services for two residents. One resident's representative was notified about the last covered Medicare day but was given the wrong notification form. Similarly, another resident's representative was informed of the last covered day but also received the incorrect form. The SSD confirmed that the representatives were informed but not given the correct Advance Beneficiary Notification (ABN).
A resident experienced a 5.32% weight loss in one month, but the facility failed to conduct a nutritional assessment, involve a dietitian, update the care plan, or notify the physician and family. Staff confirmed that no change of condition was initiated, and the weight loss was not documented as required by facility policy.
The facility failed to ensure accurate reconciliation of controlled medications in the Omnicell, as required by their P&P. Controlled substances were not counted daily, leading to discrepancies in the Cycle Count Non-Compliant Report. Interviews with pharmacy staff and the DON confirmed that only 'touched' medications were counted, contrary to policy, posing a risk for medication diversion.
A resident was administered Colace without verifying stool patterns, contrary to the facility's policy. The LVN did not check the point click care dashboard or consult with the CNA, and a list of residents with loose stools was not provided. The DON confirmed these findings.
A resident with Parkinson's disease and dementia was prescribed Nuplazid for psychosis without documented evidence of behavioral monitoring or non-pharmacological interventions. The care plan lacked details on the use of the medication for paranoid ideation, and the DON confirmed the absence of necessary documentation and monitoring.
The facility failed to properly store and label medications, with issues including unrefrigerated eye drops, mixed storage of internal and external medications, and unlabeled inhalation medication. Additionally, expired medication was found, and a nurse left medications unattended during administration. These deficiencies were confirmed by staff during observations.
The facility failed to ensure the DSS overseeing the satellite kitchen was qualified, as required by California Code. During a survey, issues were found in both the main and satellite kitchens, including unclean equipment and lack of an air gap for a juice machine, potentially affecting 42 residents. The administrator acknowledged these findings.
A resident with a documented allergy to cucumber was served cucumber during lunch, despite the facility's records indicating the allergy. The Dietary Service Supervisor confirmed the oversight and acknowledged the need to replace the allergenic item. The resident stated that consuming cucumber would lead to vomiting and illness.
The facility failed to educate staff and visitors on safe food handling for outside food, risking foodborne illnesses for residents. The DSS did not provide specific guidance on cooking and cooling temperatures, and the DSD/IP only reminded staff to label food properly. Education was limited to CNAs, and licensed staff were not informed about safe food handling practices.
A facility failed to provide necessary hospice care for a resident, including missing weekly CHHA visits and lacking documentation in the hospice log. The hospice RN was also absent from a care conference. The DON confirmed these deficiencies.
The facility's QAA committee failed to document action plans for previously identified deficiencies in respiratory care and medication storage. The DON could not provide evidence of procedures for labeling and changing respiratory equipment or logs for medication storage checks. An LVN reported only checking medications weekly, not daily as required.
The facility failed to maintain accurate infection surveillance, with discrepancies in reported infections for residents. Infection control practices in the laundry room were inadequate, with clean linens in contact with personal items. Additionally, a nurse did not follow proper hand hygiene during medication administration, and improper Foley catheter care was observed, with the catheter tip not cleaned after use.
The facility failed to document the offer and discussion of influenza and pneumococcal vaccines for two residents who lacked decision-making capacity. Consent forms were incomplete, and there was no evidence of discussions about the risks and benefits of the vaccines, posing a risk of disease acquisition.
The facility failed to maintain essential temperature logs for the Omnicell Anatomic Drug Dispensing system, as required by their policies. Despite placing a work order to replace a faulty thermometer, night shift nurses left the temperature log incomplete, potentially affecting residents' medications. Interviews with the DON and an RN confirmed the importance of daily temperature recording.
The facility failed to implement its antibiotic stewardship program, leading to inappropriate antibiotic use for a resident and two others. A resident was prescribed ciprofloxacin for a UTI despite meeting criteria for gastroenteritis, without informing the physician. Another resident received azithromycin for a cough without confirming infection criteria. A third resident was given Augmentin for pneumonia, meeting criteria for gastroenteritis, without physician notification. The facility's IP failed to review antibiotic use effectively, and the DSD/IP and RN confirmed these findings.
The facility failed to provide adequate respiratory care for two residents. A resident's nasal cannula was not stored properly, and another resident's nasal cannula and storage bag were not dated as required by facility policy. These deficiencies were confirmed by LVNs during observations and interviews.
The facility did not follow the main menu for 42 residents, serving an alternate menu without notifying them. The Director of Food and Nutrition Services confirmed the deviation from the planned menu and the lack of resident notification.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen for food prepared and served to all 38 residents. During review of the refrigerator used to store residents’ food brought in from outside sources, surveyors observed two bottles of Dr. Pepper that were unlabeled, a container of rice labeled with a resident’s name but dated 11/5/25, an unlabeled popsicle with a use-by date of 11/7/25, and two lower bins containing a dead insect and food debris. The CDM/Executive Chef and Dietary Team Lead verified these findings. The facility’s policy for food brought by family/visitors stated that food left with the resident to consume later would be labeled, dated, and stored in the refrigerator when needed, and that nursing staff would discard perishable food on or before the use-by date. Surveyors also observed additional sanitation issues in the dietary area. When the inside of the only ice machine used in the SNF was wiped with a white paper towel, black dirt was observed on the towel, and the Maintenance Staff and CDM/Executive Chef verified the finding. The plate conveyor was observed with dirt, paper, and straw at the bottom, and a clear bin containing several scoops was observed wet rather than air-dried before storage. These observations were verified by the CDM/Executive Chef and Dietary Team Lead. The report cited USDA Food Code requirements that equipment and utensils be kept clean and that items be allowed to drain and air-dry before being stacked or stored.
Failure to Verify Safe Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to determine whether it was safe and clinically appropriate for two residents to self-administer medications left at the bedside. Resident 66 was observed sitting in a wheelchair with three tablets of Renvela in a medication cup on the overbed table and was seen taking the medication by herself after the LVN had given it to her. Resident 68 was observed with a bottle of nasal spray on the overbed table and stated she had been self-administering it three times a day. For Resident 66, the medical record showed an order for sevelamer carbonate (Renvela) 800 mg three tablets a day, but there was no physician's order for self-administration of the medication. The self-administration assessment showed the resident did not want to self-administer medications, had a diagnosis that may interfere with the ability to self-administer, was not physically able to administer medications, and was not a candidate for safe self-administration. The resident's plan of care did not include a care plan problem addressing self-administration of Renvela. For Resident 68, the self-administration assessment also showed the resident did not want to self-administer medications, had a diagnosis that may interfere with the ability to self-administer, was not physically able to administer medications, and was not a candidate for safe self-administration. The medical record did not contain a physician's order for the nasal spray, and the plan of care did not include a care plan problem addressing self-administration of the nasal spray. The DON verified that both residents were not safe to self-administer their medications and that there were no physician's orders or care plan problems addressing self-administration.
Call Light Not Visible or Within Resident Reach
Penalty
Summary
The facility failed to ensure the necessary means for a resident to call staff for assistance was provided for one of 12 sampled residents. During an initial tour, Resident 27 was observed grimacing in bed and stated, "I'm shaking because I want to go to the bathroom, I don't know where my call light is." Staff were called, and a CNA assisted the resident. When the resident was transferred from the bed to the wheelchair, the call light was found by the resident's left upper thigh, covered with a blanket and bed sheet, and the resident stated it was not visible and could not be used. The facility's policy stated the call device should be placed within the resident's reach before leaving the room. Resident 27 was admitted on an unspecified date and had no capacity to make medical decisions per the H&P. The MDS showed a BIMS score of 11, indicating moderately impaired cognition, and the skilled nursing assessment showed the resident was continent of bowel and bladder. During interviews, CNA 3 acknowledged the call light was not visible and was located by the resident's left upper thigh under bedding, and LVN 1 also stated the call light should be visible and within the resident's reach.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of abuse involving Resident 15 to the CDPH, L&C Program, the Long-Term Care Ombudsman, and local law enforcement after becoming aware of the allegation. Resident 15 stated that on 11/18/25 after dinner, a staff member spoke to her in a rude and disrespectful manner, saying, "You didn't listen to what I asked you," and "Nobody likes you," and also physically knocked her hand away. Resident 15 said this type of interaction had happened multiple times in the past and that she did not feel good about the way staff treated her. She had not reported the incident to facility staff before the allegation was brought to the Administrator and DON on 11/19/25 at 1025 hours. Review of Resident 15's medical record showed she could make medical needs known, but also had moderately impaired cognitive function and required staff assistance with activities of daily living. The DON stated allegations of abuse should be reported as soon as possible within two hours to the CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement, and acknowledged the allegation should have been reported within two hours. The Administrator stated he did not believe the allegation needed to be reported because Resident 15 denied it when interviewed by facility staff, and said he would not report an incident if the resident denied it during the investigation. The facility's SOC 341 was not submitted to CDPH until 11/21/25 at 1556 hours, approximately two and a half days after the facility became aware of the allegation.
Failure to Report Abuse Allegation and Complete Change-in-Condition Monitoring
Penalty
Summary
The facility failed to ensure necessary care and services were provided for a resident involved in an allegation of verbal and physical abuse by staff. The resident stated that after dinner a staff member spoke to her in a rude and disrespectful manner, telling her, "You didn't listen to what I asked you," and "Nobody likes you," and also physically knocked her hand away. The resident reported that this type of interaction had happened multiple times in the past and stated she did not feel good about the way staff treated her. She did not report the incident to facility staff before the survey interview. The resident's medical record showed she could make medical needs known, had moderately impaired cognitive function, and required staff assistance with activities of daily living. The record did not show that the allegation of abuse was reported to the physician, that a change in condition evaluation and assessment was completed, or that the resident was monitored for changes in condition after the facility became aware of the allegation. The DON confirmed that the documentation could not be found and stated the allegation should have been treated as a change in condition, with physician notification and monitoring completed.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain safe water temperatures in resident rooms and bathroom sinks. Its policy stated that water heaters serving resident areas were to be set at no more than 120 degrees F, and maintenance staff were responsible for checking and recording water temperatures. During an observation and concurrent interview with the Maintenance Director, the water temperature measured 129 degrees F in Room A, 114 degrees F in Room B, and 125 degrees F in Room C. The Maintenance Director verified the readings and stated water temperature in resident care areas should be less than 120 degrees F to prevent burns. A review of the Engineering Department Domestic Hot Water Testing Log for November 2025 showed that on 11/21/25, sink water temperatures were checked in 27 rooms, and 12 of the 27 rooms had temperatures between 122 and 126 degrees F. The Maintenance Director verified those readings were above 120 degrees F. In an interview, Resident 62 stated she could use the bathroom without staff assistance and reported that on two occasions the sink water became too hot and she had to add cold water. Resident 62 was cognitively intact per the MDS review.
Respiratory Care Not Provided as Ordered and Oxygen Tubing Unlabeled
Penalty
Summary
The facility failed to provide necessary respiratory care for Resident 4 by not administering oxygen at the physician-ordered rate. Resident 4 was observed in bed receiving oxygen via nasal cannula at 2 liters per minute, while the physician's order dated 10/22/23 directed continuous oxygen at 3 liters per minute via nasal cannula. During the observation, LVN 5 verified the resident was receiving 2 liters per minute and then increased the oxygen to 3 liters per minute. The DON later stated the resident should have received 3 liters per minute as ordered and that staff were expected to clarify the order with the physician when the resident requested different oxygen settings. The facility also failed to ensure oxygen tubing was labeled for Resident 61. Resident 61 was observed receiving oxygen at 4 liters per minute via nasal cannula, and the tubing was not labeled or dated. RN 1 verified the tubing was unlabeled and stated it should have been labeled and changed every Sunday per facility practice. The physician's order for Resident 61 directed oxygen at 4 liters per minute via nasal cannula to maintain oxygen saturation above 92% every shift and to change the oxygen tubing and humidifier every Sunday. The IP also stated that oxygen tubing should not be on the floor and that the incentive spirometer should be bagged to prevent contamination.
Medication Administration Errors With Breakfast Dosing
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration, and the medication error rate was 8%. During observation, interview, and medical record review, one of four licensed nurses, LVN 3, was found to have two medication errors while administering medications. LVN 3 administered ferrous sulfate 325 mg to Resident 53, but the physician’s order was for one tablet by mouth one time a day with breakfast. Resident 53 had been admitted to the facility, had the capacity to make medical decisions, and his breakfast had already been served before the medication was given. LVN 3 also administered metformin HCl 500 mg to Resident 2 after breakfast instead of with breakfast as ordered. Resident 2 had been admitted to the facility, could make needs known but could not make medical decisions, and the physician’s order directed that metformin 500 mg be given one tablet by mouth one time a day with breakfast. The DON verified both findings during interview and record review, and stated the medication should have been administered with breakfast.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to provide necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. During the initial tour, a tube of Silicone Cream was observed on the sink counter inside Resident 65's room. CNA 3 verified the cream was present and stated she did not know whether Resident 65 was using it and that it should not be there. RN 1 also acknowledged the cream and stated no treatment creams should be at bedside. Review of Resident 65's record showed the resident was admitted to the facility, had capacity, and had no physician order or treatment record entry for the Silicone Cream. The medication room was also found to have oral and non-oral medications stored together. In Cabinet 1, bisacodyl rectal suppositories were stored among powdered fiber, antacid liquid, and sodium fluoride toothpaste. In Cabinet 2, fleet enema, fish oil soft gels, Florastor, Refresh Classic lubricant eyedrops, ferrous gluconate tablets, vitamin C, and vitamin E were stored together. The medication refrigerator had small brownish and blackish particles on the bottom shelf, and boxes of Isosource enteral feeding formulas and IV supplies were observed on the floor in the supply storage room. LVN 1 verified each of these findings, and the Administrator and DON were informed and acknowledged the observations.
Infection Surveillance Documentation and EBP Use Failures
Penalty
Summary
The facility failed to establish and maintain an infection control program designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. Review of the facility’s Infection Control Surveillance Policy showed that the Infection Preventionist was responsible for daily infection monitoring, maintaining surveillance logs and line lists, tracking trends and clusters, and reporting findings to the DON/Administrator and QAPI. The facility’s Infection Surveillance Monthly Report for October 2025 listed 17 total infections, including 10 community acquired infections and 7 healthcare associated infections, but the report did not show whether the residents listed met McGeer criteria or whether each resident was classified as HAI, CAI, or suspected infection. During interview and record review, the DSD/IP verified that the October 2025 surveillance report did not identify whether the listed residents were HAI, CAI, or suspected infection and did not show whether the residents’ symptoms met McGeer criteria. The DSD/IP stated the facility system generated the totals based on the data entered, but she was not able to show the list of residents who had HAI in October 2025. The DON was informed of and acknowledged these findings. The facility also failed to ensure Resident 4 was placed on EBP as ordered. Resident 4 had a physician’s order for treatment of a left lower extremity post-biopsy wound and an order dated 10/14/25 indicating the resident was on EBP due to the wound. Multiple observations of the resident’s room showed no EBP sign outside the door and no isolation cart with PPE. CNA 1 stated she had not received information that the resident was on EBP and did not wear a gown when providing high-contact care. LVN 5 was observed entering the room without performing hand hygiene and acknowledged the resident had a left leg wound and that no EBP sign was posted. The DSD/IP also verified there was no EBP sign or isolation cart in the room and stated that residents with wounds were placed on EBP to prevent the spread of MDROs.
Failure to Monitor Antibiotic Use for Residents Without Evidence of True Infection
Penalty
Summary
The facility failed to ensure antibiotic use was monitored for two residents whose conditions did not meet McGeer’s criteria for true infection. One resident was admitted after abdominal surgery and debridement of necrotic skin at the umbilicus and was receiving doxycycline; the Infection Surveillance Monthly Report listed no signs and symptoms of infection, and the Infection Screening Evaluation documented only skin/wound tenderness without showing that the symptoms met criteria for true infection. The medical record did not show that the physician was followed up with when the resident’s symptoms did not meet the criteria and the antibiotic was prescribed. A second resident was admitted with vancomycin HCL oral capsules for recurrent C. difficile, noted as prophylaxis with no end date, and the surveillance report documented no specific symptoms and no signs and symptoms of C. difficile. The Infection Screening Evaluation also showed no signs and symptoms of infection, but the record did not show that the physician was notified when the resident’s condition did not meet criteria for true infection. During interview and concurrent record review, the DSD/IP verified that both residents did not meet the criteria for true infection, and the DON was informed of the findings.
Missing Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that education on the risks and benefits of influenza and pneumococcal vaccinations was reviewed with residents and/or their representatives for eight of 11 residents reviewed for immunization. The facility’s Immunization policy, dated 11/16/24, stated that influenza, pneumococcal, and COVID-19 vaccines were to be offered to residents and staff and that residents and staff would be informed regarding the risks, benefits, and potential side effects associated with the vaccines. For Residents 5, 27, 49, 51, and 54, the medical record showed that pneumococcal vaccination was declined, but the records did not show documentation that the risks and benefits were explained before the refusals were recorded. Resident 27’s pneumococcal informed consent form showed the vaccine was declined with the reason listed as already received, and Resident 54’s form showed refusal, but neither record showed education on risks and benefits. Resident 49’s form showed refusal, and Resident 5’s form also showed refusal, but the DSD/IP stated the education was not documented. Resident 51 had no capacity to make medical decisions, and the COVID/COVID booster informed consent form showed the responsible party declined vaccination, but the record did not show documentation that the risks and benefits were explained to the responsible party. For Residents 6 and 39, the medical records did not show a pneumococcal consent form or documentation that they or their representatives were offered the vaccine and provided education on its benefits and potential side effects. Both residents stated during interview that nobody talked to them about any vaccine. For Resident 7, the influenza informed consent form showed the resident representative declined the flu vaccine, but the record did not show documentation that the risks and benefits were explained to the resident and/or representative. During interview and record review, the DSD/IP verified the missing documentation for Residents 7, 27, 54, 6, and 39, and the DON was informed of the findings.
Failure to Offer COVID-19 Seasonal Vaccine to Two Residents
Penalty
Summary
The facility failed to ensure that two of 11 sampled residents, Residents 7 and 27, were offered the COVID-19 seasonal vaccine. The facility’s Immunization policy dated 11/16/24 stated that influenza, pneumococcal, and COVID-19 vaccines are to be offered to residents and staff in accordance with CDC, CDPH, and CAL-OSHA regulations, and that residents and staff are to be informed of the risks, benefits, and potential side effects associated with the vaccine. Resident 7 was admitted to the facility and had an H&P dated 9/23/25 showing the resident could make own medical needs known. Review of the CAIR2 report did not show whether Resident 7 received the 2024/25 COVID-19 seasonal vaccine, and the medical record did not show that the updated booster was offered. Resident 27 was admitted to the facility and had an H&P dated 11/11/25 showing no capacity to make medical decisions. Review of the CAIR2 report dated 11/7/25 did not show whether Resident 27 received the 2024/2025 COVID-19 seasonal vaccine, and the medical record did not show that the updated seasonal vaccine was offered. During interview and concurrent record review, the IP/DSD verified the findings and stated the facility did not offer the COVID-19 seasonal vaccine to Residents 7 and 27; the DON was later informed and acknowledged the findings.
Residents Not Informed How to Contact State Agency
Penalty
Summary
The facility failed to ensure that seven residents who attended a residents’ council meeting were provided with information on how to contact the local State agency. During the meeting, Residents 4, 28, 35, 39, 45, 62, and 68 stated they did not know how to contact the local State agency if they needed to file a complaint. When the Activities Director was interviewed, she stated that she showed the residents the Ombudsman poster and assumed the Ombudsman office could provide the State agency contact information if needed. Medical record review showed that the residents involved had the capacity to understand and make decisions or were able to make their needs known. Resident 4’s H&P dated 10/6/25 showed capacity to understand and make decisions. Resident 28’s H&P dated 10/6/25 showed capacity to understand and make decisions. Resident 35’s H&P dated 6/6/25 showed she was able to make her needs known. Resident 39’s H&P dated 10/6/25 showed she was able to make her needs known. Resident 45’s H&P dated 6/6/25 showed she was able to make her needs known. Resident 62’s H&P dated 11/16/25 showed she was able to make her needs known. Resident 68’s H&P dated 11/15/25 showed capacity to understand and make decisions.
Failure to Notify LTC Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The facility failed to ensure the necessary transfer/discharge services were completed for one of two closed-record sampled residents, Resident 58. Resident 58 was admitted to the facility and was later transferred to an acute care hospital. Review of the Notice of Transfer/discharge dated 9/21/25 showed that Resident 58 was discharged to the acute care hospital, and the box indicating that a copy was sent to the LTC Ombudsman was checked. During interview and record review on 11/25/25, the SSD stated she would send a copy of the discharge order by email to the LTC Ombudsman and document the notification in a log after sending it. However, when asked to show the email notifying the LTC Ombudsman of Resident 58's transfer to the acute care hospital, the SSD could not locate any email. The LTC Ombudsman later confirmed she did not receive any notification about Resident 58's transfer/discharge to the acute care hospital.
Inaccurate respiratory assessments failed to document nebulizer treatment
Penalty
Summary
The facility failed to ensure the medical records for two sampled residents were accurate because the Skilled Nursing Assessments did not document nebulizer treatment that was reflected in the MAR. Resident 7 was admitted to the facility and had an H&P stating the resident could make own medical needs known. The physician’s order summary showed an order for Ipratropium-Albuterol inhalation solution via nebulizer every six hours as needed for SOB/wheezing, and the November 2025 MAR showed the medication was administered on multiple dates. However, the Skilled Nursing Assessments in the respiratory section on several dates did not show documentation that Resident 7 was on nebulizer treatment or received the treatment as recorded in the MAR. Resident 27 was admitted to the facility and had an H&P stating the resident had no capacity to make medical decisions. The order summary showed an order for Ipratropium-Albuterol inhalation solution via nebulizer every four hours as needed for SOB/wheezing, and the November 2025 MAR showed the medication was administered on multiple dates. Despite this, the Skilled Nursing Assessments under the respiratory section on several dates did not document that Resident 27 was on nebulizer treatment or received the treatment as documented in the MAR. During interview and record review, the ADON/MRD verified the findings and stated the respiratory assessments should have been documented accurately, and the DON acknowledged that the residents were on nebulizer medications and that the Skilled Nursing Assessments should have checked off yes on the nebulizer treatment.
Delay in Physician Notification of RD Recommendations Following Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident received timely and appropriate services to maintain optimal nutritional status. Specifically, the resident experienced a weight loss of 6 pounds (4.3%) over six days, as documented in the medical record. The registered dietitian (RD) conducted a nutrition assessment and recommended daily multivitamin with minerals, snacks three times daily, and Glucerna shakes with meals due to inadequate oral intake. These recommendations were documented on 9/9/25. However, the RD's recommendations were not communicated to the physician until nine days later, resulting in a delay in obtaining the necessary physician orders for the interventions. Facility policy required timely monitoring and intervention for undesirable weight changes, but the charge nurses did not relay the RD recommendations to the physician as required. This delay was acknowledged by both the LVN and the DON during interviews, confirming that the resident did not receive the recommended nutritional interventions in a timely manner.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one of the sampled residents, identified as Resident 1. The deficiency was identified during a review of the facility's policies and procedures, which require that all services provided to residents, progress toward care plan goals, and any changes in the resident's condition be documented accurately in the medical record. Resident 1, who was admitted to the facility with moderately impaired cognition, had a documented fall prior to admission. However, the fall risk assessment inaccurately indicated that Resident 1 had no history of falls within the last six months. The inaccuracy in the fall risk assessment was confirmed during interviews with LVN 1 and the ADON. LVN 1 acknowledged that the assessment should have reflected a history of one to two falls, rather than none, and noted that such inaccuracies could lead to misinterpretation. The ADON also confirmed the error and expressed concern that inaccurate documentation could delay necessary services. This failure to maintain an accurate medical record posed a risk to Resident 1's care, as it could lead to inadequate fall prevention measures being implemented.
Failure to Suspend CNAs During Abuse Investigation
Penalty
Summary
The facility failed to adhere to its abuse protocol during an investigation of an alleged physical abuse incident involving a resident. The resident, who was capable of making her own medical decisions, reported an allegation of physical abuse against two CNAs. According to the facility's policy, staff members accused or suspected of abuse should be suspended pending the completion of the investigation. However, the facility did not suspend the two CNAs involved in the allegation during the investigation period. The investigation file showed that the CNAs continued to work, although they were not assigned to the resident who made the allegation. The facility's staffing sheets confirmed that the CNAs worked during the investigation period but were given different assignments. The Director of Nursing acknowledged that the CNAs should have been suspended to ensure the safety of the resident and other residents in the facility.
Failure to Monitor Resident After Abuse Allegation
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and/or maintained her highest practicable physical well-being. Specifically, the facility did not monitor the resident's safety and psychosocial well-being or develop a care plan after the resident reported an abuse allegation. The resident alleged that two CNAs were rough while changing her diaper and laughed at her during the incident. Despite this report, the facility did not conduct the required 72-hour monitoring of the resident following the abuse allegation. The medical record review revealed that there was no care plan established to address the resident's safety and psychosocial well-being after the abuse allegation. Interviews with the RN and the DON confirmed these findings, acknowledging that the resident's medical record should have included a care plan and 72-hour monitoring by nursing and social services. This oversight had the potential to impact the resident's receipt of necessary care and services.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitation requirements in the kitchen, posing a risk of food-borne illnesses to 42 residents. Observations revealed unsanitary conditions, including multiple metal sheet trays and baking pans with solid black residue, a whisk with a burnt handle, a melted spatula, a cracked spatula, and heavily marred cutting boards. Additionally, a gray plastic bin holding clean kitchen tools was found with water and black particles on the inner bottom surface. These conditions violate the USDA Food Code 2022, which mandates that utensils and food contact surfaces must be clean, durable, and easily cleanable. Further observations showed that a dietary aide handled clean plates with the same gloves used for dirty dishes without changing gloves or washing hands, increasing the risk of cross-contamination. Additionally, a juice machine lacked an air gap for backflow prevention, as required by the USDA Food Code 2022, which could lead to contamination of the juice provided to residents. These deficiencies were verified by the Maintenance Technician and acknowledged by the facility's Administrator, DON, and DSS.
Failure to Implement Two-Person Assist Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff implemented a two-person assist for transfers as required by the care plan for a resident, resulting in an injury. The resident, who had impaired mobility and required substantial or maximal assistance for transfers, was transferred by a single CNA from a shower chair to a bed. During this transfer, the resident's leg was caught between the nightstand, leading to a right ankle fracture. The CNA was unaware of the requirement for a two-person assist, and it was noted that other staff had also been assisting the resident without additional help. The resident's medical records indicated a history of generalized weakness and deconditioning, necessitating extensive assistance for transfers. The care plan, developed by the Case Manager and verified by the Director of Rehabilitation, clearly stated the need for a two-person assist due to the resident's right knee osteoarthritis and decreased activity tolerance. Despite these documented needs, the staff failed to adhere to the care plan, resulting in the resident's injury.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safety of self-administration of medications for one resident, identified as Resident 24. During an observation, two tubes of Voltaren gel, a topical pain medication, were found at the resident's bedside without a physician's order or care plan addressing self-administration. The facility's policy requires an assessment by the interdisciplinary care team to determine if self-administration is safe and appropriate, and to document this in the resident's care plan. However, Resident 24's medical records did not contain evidence of such an assessment or documentation. Interviews with the resident and a registered nurse (RN 1) revealed that the resident was applying the Voltaren gel independently for knee pain, despite not being deemed a candidate for safe self-administration according to a prior assessment. RN 1 confirmed the absence of a physician's order or care plan for self-administration, indicating a lapse in following the facility's policy and procedures for medication management.
Failure to Document and Update Advance Directives
Penalty
Summary
The facility failed to ensure that advance directive information was documented and offered to three residents, leading to potential treatment against their wishes. For Resident 22, the facility did not obtain and place a copy of the advance directive in the medical record, despite the POLST indicating its existence. The Social Services Director (SSD) confirmed the absence of the document and acknowledged not contacting the family for a copy. Similarly, Resident 24's advance directive was not available in the medical record, even though assessments indicated its existence and a family member's intention to provide it. The SSD admitted the oversight. For Resident 25, the POLST was not updated to reflect the formulation of an advance healthcare directive, despite documentation of its existence. The SSD verified this discrepancy during a review.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNOC) after the termination of Medicare Part A services for two nonsampled residents, identified as Resident 45 and Resident 47. For Resident 45, the admission record indicated that the last covered day of Medicare Part A services was on August 3, 2024. Although the resident's representative was notified about the last covered Medicare day on May 17, 2024, they were incorrectly given a copy of the CMS 20052 SNF Beneficiary Protection Notification Review instead of the Advance Beneficiary Notification (ABN). Similarly, for Resident 47, the admission record showed that the last covered day of Medicare Part A services was on May 15, 2024. The resident's representative was informed of the last covered Medicare day on May 13, 2024, but was also provided with the CMS 20052 SNF Beneficiary Protection Notification Review instead of the ABN. During an interview and concurrent medical record review on October 22, 2024, the SSD confirmed that the representatives of both residents were informed of the last covered day for Medicare but were not given a copy of the ABN.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to provide timely intervention for a resident who experienced significant weight loss. Resident 22, who was part of a sample reviewed for weight loss, lost 5.32% of their body weight in one month. Despite this significant weight change, there was no assessment from nutritional services, no intervention from a registered dietitian, no care plan developed, and no notification to the resident's physician or family. This lack of action was contrary to the facility's policy and procedures, which require a Nutrition at Risk Review, physician and family notification, and care planning with nutritional goals when significant weight loss is identified. During an interview and medical record review, it was confirmed that the facility's staff, including RN 2 and LVN 1, did not initiate a change of condition for Resident 22. The staff acknowledged that the resident's weight loss was not documented in a care plan, nor was there a progress note indicating that the physician or family had been notified. The facility's process involves using a communication board on the electronic health record system to document changes, but this was not done for Resident 22. The failure to follow these procedures had the potential to result in continued nutritional decline and negative outcomes for the resident.
Failure in Controlled Medication Reconciliation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the accurate reconciliation and disposal of medications, specifically controlled substances. The facility's policy and procedure (P&P) required that controlled medications in the Omnicell, an automatic drug delivery system, be counted and verified daily by authorized staff. However, it was found that the facility did not comply with this requirement, as evidenced by discrepancies in the Cycle Count Non-Compliant Report. The report listed several controlled medications, such as acetaminophen-cod #3, alprazolam, hydrocodone-acetaminophen, hydromorphone, lorazepam, morphine sulfate, oxycodone, pregabalin, temazepam, tramadol, and zolpidem tartrate, which had not been counted for extended periods, some dating back several months. Interviews with the pharmacy staff and the Director of Nursing (DON) revealed that the night shift nurses were only counting controlled medications that were categorized as 'touched' during their shift, contrary to the facility's P&P that required all controlled substances to be counted daily. The DON confirmed that the facility was not compliant with the daily counting requirement, leading to the risk of medication diversion. The findings were verified through document reviews and interviews, highlighting a significant lapse in the facility's medication management practices.
Failure to Monitor Stool Softener Administration
Penalty
Summary
The facility failed to ensure proper monitoring of a nonsampled resident's medication regimen, specifically concerning the administration of a stool softener, Colace. The facility's policy requires that medication administration be in accordance with applicable laws and that licensed nurses confirm the Medication Administration Record (MAR) reflects the most recent medication order. However, during an observation, a Licensed Vocational Nurse (LVN) administered Colace to a resident without verifying if the resident was experiencing loose stools, as required by the medication order. The LVN admitted to not checking the resident's stool pattern through the facility's point click care dashboard or consulting with the Certified Nursing Assistant (CNA) on duty. The LVN also mentioned that a list of residents with loose stools, which is typically provided, was not available to her that day. This oversight was confirmed during an interview and concurrent medical record review with the Director of Nursing (DON), who verified the findings.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 25, was free from unnecessary psychotropic medications. Resident 25, who was admitted with diagnoses including Parkinson's disease and unspecified dementia, was prescribed Nuplazid, an antipsychotic medication, for psychosis related to Parkinson's disease manifested by paranoid ideation. However, there was no documented evidence of behavioral monitoring for episodes of paranoid ideation or any non-pharmacological interventions provided for Resident 25. Additionally, the care plan did not address the use of Nuplazid for the manifestation of paranoid ideation or include documentation of non-pharmacological interventions. During an interview and medical record review with the Director of Nursing (DON), it was confirmed that there was no documentation of Resident 25's episodes of paranoid ideation, nor was there any monitoring of these episodes or documentation of non-pharmacological interventions. The DON also verified the absence of a care plan for the use of Nuplazid medication for psychosis related to Parkinson's disease manifested by paranoid ideation. This lack of documentation and care planning indicates a failure to adhere to the facility's policy on antipsychotic medication use and informed consent, which requires that non-pharmacological interventions be attempted and documented before considering antipsychotic medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. Resident 7's eye drop medication was not refrigerated as required, and Resident 22's cough medication was stored alongside a topical ointment, contrary to the facility's policy of separating internal and external medications. Additionally, Resident 686's inhalation medication lacked an opened date label, violating the facility's policy. The bottom drawer of Medication Cart 1 was found unclean, with spill residue and dried medication debris. Furthermore, expired medication was found in the medication storage room, specifically a bottle of aspirin with an expiration date of January 2024. During a medication administration observation, a licensed nurse left medications for Resident 27 unattended on two occasions. The nurse left two eye drop medications on the resident's overhead table while performing other tasks, such as washing hands and calling for assistance. This action was against the facility's policy, which states that medications should not be left unattended. These deficiencies were verified by the staff present during the observations, including a licensed vocational nurse, the director of nursing, and a registered nurse.
Unqualified DSS and Kitchen Deficiencies
Penalty
Summary
The facility failed to ensure that the Dietetic Services Supervisor (DSS) responsible for overseeing the satellite kitchen was qualified to manage the day-to-day functions of the food services department. This deficiency was identified during a recertification survey conducted from October 21 to October 24, 2024. The DSS was responsible for managing the skilled nursing facility's (SNF) satellite kitchen, where food was prepared in the main kitchen and then transported to the SNF. The main kitchen was managed by an executive chef, and a registered dietitian (RD) was employed part-time, working two days a week. However, the facility's documents did not provide evidence that the DSS met the qualifications required under the California Code, Health and Safety Code - HSC S 1265.4. During the survey, multiple issues were found in both the main and satellite kitchens, including unclean and improperly maintained kitchen utensils and equipment, as well as a failure to ensure an air gap for a juice machine. These deficiencies had the potential to negatively affect the health and well-being of 42 residents who consumed food prepared in the kitchen. The facility's administrator acknowledged these findings during an interview conducted on October 23, 2024.
Resident Served Allergenic Food Despite Known Allergy
Penalty
Summary
The facility failed to ensure that a resident with a known food allergy was not served an allergenic item, leading to a deficiency. Resident 27, who has an allergy to cucumber as documented in their dietary communication dated 4/12/24, was observed eating lunch independently on 10/21/24 and was served cucumber on their main plate. During an interview and diet card review with the Dietary Service Supervisor (DSS), it was confirmed that the resident had an allergy to cucumber. The DSS acknowledged the error and stated they would replace the cucumber. Resident 27 later confirmed in an interview that consuming cucumber would cause them to vomit and become ill.
Deficiency in Safe Food Handling Education
Penalty
Summary
The facility failed to ensure that education was provided to staff and family/visitors on safe food handling of outside food, which could potentially lead to foodborne illnesses among the medically vulnerable resident population. The facility's policy allowed food to be brought in by visitors and family, but there was a lack of comprehensive education on safe food handling practices. The DSS stated that she informed residents and visitors about how long food could be kept in the refrigerator but did not provide specific guidance on proper cooking and cooling temperatures or distribute literature on safe food handling. The DSD/IP admitted to only reminding staff to label food properly and ensure it was appropriate for the resident's diet, without providing in-depth education on safe food handling practices. The in-services were limited to CNAs and did not include licensed staff, who were responsible for reheating food. LVN 2 confirmed that she did not educate visitors on safe food handling, and reheating was done by kitchen staff, not licensed staff or aides. The facility's leadership, including the Administrator and DON, acknowledged these findings.
Failure to Provide Required Hospice Services
Penalty
Summary
The facility failed to provide necessary hospice care and services for a resident, identified as Resident 22, who was part of a sample reviewed for hospice services. The deficiencies included the failure to ensure that the resident received a hospice aide visit once per week as ordered by the physician. Additionally, the hospice log lacked documentation regarding the Certified Home Health Aide (CHHA) visit. Furthermore, the hospice Registered Nurse (RN) was not included in the resident's Care Conference/Care Plan Meeting. The facility's policy and procedure for hospice services, revised in November 2024, outlined the responsibilities of hospice providers and the facility in managing the resident's care. However, a review of the medical records and facility documents revealed that the CHHA visits were not conducted as required, with no visits documented from March to October 2024, except for a few in May. The Director of Nursing (DON) confirmed these findings. Additionally, the hospice case manager was unable to attend a care conference meeting, and there was no documentation of hospice involvement in the resident's care conference.
Deficiencies in Respiratory Care and Medication Storage
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee identified and developed action plans to address deficiencies noted in the previous recertification survey. Specifically, the facility did not have documented evidence of action plans to correct issues related to respiratory care and medication storage. These deficiencies were cited again during the current recertification survey, indicating a lack of effective corrective measures. The absence of documentation for the respiratory care process, such as labeling and dating respiratory equipment, and the lack of a documented medication storage improvement process were highlighted during interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN). During the survey, the DON was unable to provide documentation to support the training and procedures claimed to be in place for respiratory care, such as labeling and changing respiratory tubing. Similarly, the DON could not provide logs or documentation for the medication storage checks that were supposed to be conducted daily by the charge nurse. An LVN interviewed stated that he only checked his medication chart once a week and only reviewed the morning medications he would administer, rather than the entire cart. This inconsistency in practice and lack of documentation contributed to the repeated citation of deficiencies in respiratory care and medication storage.
Infection Control Deficiencies in Surveillance, Laundry, and Hygiene Practices
Penalty
Summary
The facility failed to maintain an accurate infection surveillance program for September and October 2024. Several discrepancies were noted in the Infection Surveillance Reports, where residents were documented with incorrect infections. For instance, Resident 20 was reported to have a urinary tract infection but met the criteria for gastroenteritis. Similarly, Resident 25 was documented with pneumonia but met the criteria for gastroenteritis. These inaccuracies were confirmed by the Director of Staff Development/Infection Preventionist (DSD/IP) and Registered Nurse 1/Infection Preventionist (RN 1/IP), who acknowledged that the Infection Control Surveillance should be accurate for effective reporting and intervention. In the facility's laundry room, infection control practices were not properly implemented. Observations revealed that clean linens were in contact with personal items such as a radio, charger, sweater, and hat, which were placed on the folding area. This was verified by the Director of Housekeeping, indicating a breach in maintaining a sanitary environment for handling clean laundry. Additionally, there were lapses in hand hygiene practices by a licensed nurse (LVN 1) during medication administration for a resident. LVN 1 failed to perform hand hygiene after removing gloves and before donning new ones, as well as after touching potentially contaminated items like a TV remote and call light. Furthermore, improper Foley catheter care was observed for another resident, where the catheter tubing tip was not cleaned after draining urine, and the urinal was inadequately rinsed and stored. These practices were confirmed by the involved staff and the DSD, highlighting a failure to adhere to infection control protocols.
Failure to Document Vaccine Offer and Discussion
Penalty
Summary
The facility failed to ensure that two residents were offered the influenza and pneumococcal vaccines in accordance with CDC guidelines. Resident 4, who lacked the capacity to make medical decisions, had a blank consent form for the pneumococcal vaccine, and there was no documentation of refusal or discussion of risks and benefits with the resident or their representative. Although the facility claimed that Resident 4 was offered the PPV 23 vaccine, they could not provide evidence of this offer or any related discussions. Similarly, Resident 25, also lacking decision-making capacity, had declined both the influenza and pneumococcal vaccines, as indicated by marks on their consent forms. However, there was no documentation to support that the risks, benefits, and potential side effects of the vaccines were discussed with the resident or their representative. The facility's staff confirmed these findings during interviews, and the lack of documentation posed a risk of the residents acquiring influenza and pneumonia.
Failure to Maintain Temperature Logs for Drug Dispensing System
Penalty
Summary
The facility failed to maintain essential temperature logs for the Omnicell Anatomic Drug Dispensing system, which is crucial for ensuring the safe operating conditions of the equipment. According to the facility's policies and procedures, medications and biologicals should be stored at appropriate temperatures as per the United States Pharmacopeia guidelines and manufacturer guidance. The facility's policy also requires daily monitoring of the temperature in medication storage areas. However, a review of the Automated Drug Delivery System (ADDS) Daily Temperature and Cycle Count Log revealed multiple instances where the temperature gauge was either blank or not working during the night shift across several months. Interviews with the Director of Nursing (DON) and a registered nurse (RN) confirmed that the temperature should be recorded daily. Despite placing a work order to replace the faulty thermometer, the night shift nurses continued to leave the temperature log incomplete. The DON and RN acknowledged that failing to accurately record temperature monitoring could potentially affect the residents' medications. The facility's Pharmacy ADDS Checklist also indicated that any concerns, such as temperature excursions, should be reported to the DON and pharmacy, with documentation of who was notified and the actions taken to resolve the issues.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, leading to inappropriate use of antibiotics for one sampled resident and two nonsampled residents. Resident 20 was prescribed ciprofloxacin for a urinary tract infection despite meeting the McGeer's Criteria for gastroenteritis, with no documented evidence that the physician was informed of the discrepancy. Similarly, Resident 9 was given azithromycin for a cough without documentation indicating whether the infection met the criteria for a true infection. Resident 25 was prescribed Augmentin for pneumonia, although the resident met the criteria for gastroenteritis, and there was no evidence that the physician was informed of this inconsistency. The facility's Infection Preventionist (IP) or designee was responsible for reviewing antibiotic utilization as part of the antibiotic stewardship program, but failed to identify and address these inconsistencies. During interviews, the Director of Staff Development/Infection Preventionist (DSD/IP) and a registered nurse (RN 1/IP) confirmed the findings and acknowledged that the facility should have notified the physician or obtained clarification for the use of antibiotics when residents did not meet the criteria. The Administrator and Director of Nursing (DON) also acknowledged these findings, indicating a lapse in the facility's adherence to its own policies and procedures regarding antibiotic use.
Inadequate Respiratory Care Practices
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident 17 and Resident 22, as observed during a survey. For Resident 17, the nasal cannula tubing was not stored in a sanitary manner when not in use. It was observed hanging on the concentrator instead of being stored in a bag, as required by the facility's policy. This observation was confirmed by LVN 3 during an interview, and the Director of Nursing (DON) was informed of the findings. For Resident 22, the facility did not date the nasal cannula tubing and respiratory storage bag, which is a requirement according to the facility's policy on oxygen administration. The policy mandates that oxygen equipment should be changed and dated every Sunday by the night shift staff. During an observation, it was noted that Resident 22's nasal cannula and storage bag were undated and unlabeled. This was verified by LVN 2 during a concurrent interview. These deficiencies in respiratory care practices had the potential to affect the respiratory health and well-being of the residents receiving such care.
Failure to Follow Main Menu and Notify Residents
Penalty
Summary
The facility failed to ensure that the main menus were followed for all 42 residents who consumed food prepared in the kitchen. According to the facility's policy and procedure titled 'Menu Alternatives' dated 2018, the Director of Food and Nutrition Services is responsible for supervising meal preparation and ensuring the menu is followed and served as planned. However, on the specified date, the lunch main menu, which included Burgundy Beef Tenderloin Tips, Parslied Noodles, and Seasoned Spinach, was not served. Instead, the alternate menu, which included Turkey Pot Pie and Seasoned Spinach, was prepared and served without notifying the residents of the menu change. This was confirmed through observation and interviews with the Director of Food and Nutrition Services, who acknowledged the deviation from the planned menu and the lack of resident notification.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,479 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lake Forest
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laguna Hills Health And Rehabilitation Center | 1.2 mi | ★★★★★ | 49 | 0 |
| Villa Valencia Healthcare Center | 1.2 mi | ★★★★★ | 7 | 0 |
| Palm Terrace Healthcare & Rehabilitation Center | 1.7 mi | ★★★★★ | 27 | 0 |
| Trabuco Hills Post Acute | 1.9 mi | ★★★★★ | 58 | 0 |
| Orchards Skilled Nursing | 5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.