Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at French Park Care Center during CMS and state inspections, most recent first.
A facility failed to answer call lights in a timely manner for two residents. One resident with moderate cognitive impairment and dependence for toileting hygiene was left waiting more than 20 minutes to be cleaned after a bowel movement, and the family reported repeated long waits, including at night. Another resident with intact cognition and dressing assistance needs waited for help changing a wet shirt after spilling liquid, while staff stated they were busy with meds and did not notice the call lights.
A resident with stroke-related slurred speech and expressive aphasia was verbally abused by another resident near the nurses’ station while the other resident was on 1:1 observation for wandering and indecent behavior. Staff reported the resident used derogatory, gender-based language and mocked the resident’s speech; both an LVN and a CNA described the interaction as verbal abuse. The affected resident said the comments made her angry and upset, while an RN who heard the exchange did not consider it abuse.
Failure to Timely Report Resident-to-Resident Verbal Abuse Allegation: Staff witnessed a resident-to-resident verbal altercation in which one resident used derogatory, gender-based, and threatening language toward another resident while the resident was on 1:1 observation. The CNA, charge nurse, and RN supervisor were aware of the incident, but the Administrator was not informed at the time, and the allegation was not reported to CDPH L&C, the ombudsman, or law enforcement until much later, despite facility policy requiring immediate reporting of suspected abuse.
A resident-to-resident verbal abuse allegation was not immediately investigated after one resident used derogatory and mocking language toward another resident near the nurses’ station. The involved resident had been on 1:1 observation, and the other resident had a stroke history with expressive aphasia. Staff interviews confirmed the interaction was witnessed by an LVN and an RN supervisor, but the Administrator was not informed at the time, and the allegation was not reported to CDPH/L&C until much later.
A resident with a hx of stroke and expressive aphasia was verbally abused by another resident, who used derogatory language toward her. Although facility policy required care planning for new problems and for changes related to abuse, the resident’s care plan was not initiated or revised to address the incident. RN and DON interviews confirmed that no care plan had been created for the event.
A resident with decision-making capacity and an existing behavior care plan became aggressive with a CNA and then had a verbal altercation with another resident, using derogatory language and mocking the resident’s speech. The care plan was not revised to reflect the new behavior, and RN and DON confirmed the omission.
A facility failed to provide timely and accurate med administration for three residents and failed to ensure controlled drugs on one med cart were signed off by two licensed nurses. One resident’s amlodipine was not documented as given, two other residents received 0900 meds after the scheduled window, and a methadone dose and several other meds were documented late. The controlled drug count record for one cart also lacked required dual nurse signatures on multiple shifts.
Medication Administration Not Timely for Resident With Chronic Pain: A resident with chronic pain syndrome had orders for Pregabalin, Buprenorphine HCl, and Gabapentin scheduled for 0400, 1200, and 2000 hours. MAR review showed the 0400 doses were given around 0600 instead of within the facility’s required 1-hour window, and the DON verified the medications were not administered in accordance with the provider’s order and facility policy.
A resident with diabetes had insulin discontinued and alternative glucose management ordered, but the care plan still listed Insulin Glargine, Insulin Lispro, and Metformin for diabetes management. During an interview and record review, an LVN confirmed the care plan had not been revised to reflect the resident’s current diabetes interventions.
Unattended Medicated Creams Left at Resident Bedside: A resident had two cups of medicated cream left on the bedside table with labeled tongue depressors while waiting for the Treatment Nurse to apply them. The resident had orders for Nystatin cream to the back for tinea corpus and Triamcinolone cream to the arms for psoriasis. The Treatment Nurse confirmed the creams should not have been left unattended, and the facility policy required meds to be under direct observation or locked in storage.
A resident with impaired mobility and care plan interventions for safe transfers sustained a right shin skin tear, abrasion, and hematoma when an RNA transferred her from bed to wheelchair without a gait belt; the resident reported her leg struck the wheelchair and the DON’s investigation concluded the transfer was not secured. In a separate finding, a resident who could smoke with supervision had cigarettes and lighters left within reach at bedside on multiple observations, despite the facility’s smoking policy requiring smoking materials to be stored appropriately.
Surveyors found multiple failures in medication labeling, storage, and disposal, including unlabeled lidocaine patch packets removed from their labeled box, expired ferrous gluconate, cyclobenzaprine, and clonidine left in active stock, and insulin pens used beyond their 28-day beyond-use date. Multi-dose vials and insulin pens, including cyanocobalamin, Novolog, Lantus, and Humalog, lacked required open dates despite facility policy and manufacturer instructions. In addition, a cognitively intact resident had a personal antacid container from home on the overbed table while PRN antacid and simethicone orders were not documented as given, and another resident who could not make decisions had a bottle of povidone-iodine left on the overbed table, with nursing staff acknowledging that medications should not be kept at bedside.
Respiratory equipment and oxygen care were not consistently maintained for several residents. Staff observed dirty oxygen concentrator filters, nebulizer masks and tubing that were not changed or labeled as expected, CPAP tubing and headgear that had not been cleaned on schedule, and a resident receiving oxygen at a rate that did not match the documented order. One resident was also receiving continuous O2 via NC without a physician order, without a care plan problem, and without an oxygen warning sign posted on the room door.
PRN narcotic pain management was not carried out as ordered for two residents. One resident with chronic back and generalized pain had oxycodone documented and given at pain levels of 0 or 3, with required nonpharmacological measures and effectiveness documentation not reflected in the record. Another resident with intact cognition received hydrocodone-acetaminophen for a pain level below the ordered moderate-to-severe pain range, and an LPN acknowledged the medication should not have been given.
Multiple residents receiving HD had incomplete dialysis communication records and missing bedside emergency kits. Staff found no dialysis emergency kit at the bedside for several residents with catheters or an AV shunt, and one resident’s record showed missing access-site and post-treatment documentation. For another resident, the HD center’s instruction to hold metoprolol on dialysis days was not reflected in the MAR, and the physician was not shown to have been notified. A resident on fluid restriction also had a water pitcher at bedside and inconsistent I&O documentation.
Surveyors found a 12.5% med error rate after observing medication passes for three residents. One resident missed a scheduled amlodipine dose because it was not available, and another missed apixaban and metoprolol doses for the same reason, with the pharmacy contacted later about the missing meds. A third resident’s GT meds were crushed, mixed together in water, and given all at once instead of being administered separately with flushing between each med as required by policy and accepted practice.
Menu Not Followed and Alternative Meal Not Offered: The facility served pork cutlet with a sweet glaze instead of the sour cream sauce listed on the menu, and the cook did not notify DSS of the substitution. In a separate event, a resident with capacity refused breakfast and lunch, stated he was not offered an alternative menu, and staff could not produce documentation of a substitution order form or alternative meal offer.
Pureed Diet Foods Served in Runny Consistency: The facility failed to follow puree texture guidelines for residents ordered a pureed diet. During a tray line observation, a resident’s pureed pork, bread, green beans, and orzo rice were runny and did not hold their shape. The RD verified the findings and stated pureed entrees should hold their shape and that food prepared too watery may lead to aspiration. Review of the facility P&P showed pureed foods should have a smooth, soft, homogenous consistency.
Kitchen Food Safety and Sanitation Deficiencies: Surveyors found multiple unlabeled food items, including sandwiches, nutritional shakes, and juice connected to a dispenser without required date markings. They also observed food residue and stains on kitchen equipment and utensils, chipped and damaged spatulas, and several food items past their use-by or best-by dates. DSS 1 verified the findings, and the Administrator and DON were informed.
Infection surveillance was incomplete because the IP tracked only residents on antimicrobials and did not include residents with signs and symptoms of infection who were not prescribed antibiotics. Surveyors also found multiple infection control lapses, including dirty GT pumps, a GT syringe not changed daily, a suction machine placed on the floor, a blanket taken from a soiled linen cart, and a CNA providing care without the required gown for a resident on EBP. The facility also did not document Legionnaire’s screening for pneumonia cases, and one resident with a GT had EBP care planned but no corresponding order.
The facility failed to fully apply its antibiotic stewardship program when it did not document whether two residents’ infections met McGeer’s criteria or whether the infections were CAI or HAI. Surveillance reports and infection screening evaluations for one resident on IV vancomycin and another resident on oral vancomycin for C-difficile did not include the required infection classification details, and the IP stated uncertainty about the CAI designation on the report.
Surveyors found that the facility did not ensure accurate reconciliation of controlled medications on one medication cart when required signatures were missing from the Controlled Drugs - Count Record for a PM shift change. A nurse confirmed that two licensed nurses are required to sign the record at each shift change to verify the narcotic count, and the DON stated that this is the facility’s expectation for all licensed nurses. The DON and the Administrator acknowledged that the absence of these signatures represented a failure to complete the required controlled drug count and documentation, with the report noting the potential for inaccurate reconciliation and drug diversion.
The facility failed to preserve dignity for two residents. One CNA was observed standing over a resident while feeding the resident, and the CNA acknowledged he should have been sitting in a chair. Another resident with an indwelling urinary catheter had a drainage bag hanging visibly from the bed without a privacy cover, and CNA and RN interviews confirmed the bag could be seen from the doorway.
Incomplete informed consent for psychotropic medications: A resident with no capacity to make decisions was ordered and administered olanzapine, escitalopram, and Depakote via GT, but the psychotherapeutic drug consent forms were incomplete. The forms were missing required risk/side effect information and signatures from the prescriber and resident or resident representative, and RN and DON acknowledged the forms were not complete.
Unsafe self-administration and bedside storage of medications were identified for two residents. One resident had an Albuterol HFA inhaler at the bedside without a physician order to self-administer it, despite an assessment showing he needed assistance and preferred the nurse to give all meds. Another resident with intact cognition had eye and ear drops left on the bedside table for self-administration, but there were no physician orders allowing self-administration.
A resident with severe cognitive impairment had an Advance Directive Acknowledgement form in the chart showing an advance directive was executed, but the actual document was not maintained in the medical record. During a concurrent review, the SSD verified the copy was missing, and the DON acknowledged the finding.
Delayed physician notification of critical lab results: A resident had critically low hemoglobin and glucose values on a lab report, but the LPN marked the report as reviewed without actually reviewing all results and the physician was not notified for more than nine hours. When an RN later identified the critical hemoglobin value, the physician was finally contacted and ordered transfer to an acute care hospital for further evaluation and treatment.
Failure to Monitor Psychotropic Medication Use: A resident received lorazepam for anxiety manifested by restlessness and inability to relax, but the record did not show an order for monitoring those specific behaviors. The facility policy required psychotropic medications to be used only when appropriate for a documented condition and when the resident’s response was monitored and documented. An LPN stated she could not find documentation showing the resident was monitored for the targeted behaviors, and the DON stated residents on psychotropic medications should be monitored for the specific behaviors related to the medication.
Failure to timely report an abuse allegation: A resident reported that a CNA used a wooden object to penetrate her body, and the Ombudsman and family member described the incident as involving force and a dark room. The facility’s record did not show the allegation was reported to CDPH, law enforcement, or the Ombudsman within the required timeframe, and the Administrator could not find documentation that the report had been made when staff became aware of it.
Failure to Investigate Abuse Allegation: The facility did not timely investigate an abuse allegation involving a resident who reported that a CNA used a wooden object to penetrate her body. The Ombudsman and the resident’s family member said the allegation had been reported to the prior Administrator, but no investigation record was found. The resident later stated no one followed up with her and that the CNA continued to provide care, while the resident’s record also noted bipolar disorder with statements described as delusional and unfounded.
PASRR Level 1 screening was not completed before a resident was admitted to the facility. The resident had a history of depression and psychoactive substance abuse, and the MDS Coordinator verified the screening had not been done prior to admission.
A resident sustained a skin tear and hematoma during a staff transfer, but the wound assessments did not include measurements on the initial or weekly checks. The facility also failed to complete hospice care conference documentation and obtain the hospice plan of care for one resident, failed to rotate insulin injection sites for two residents, and missed required neuro checks after an unwitnessed fall for another resident.
Failure to Notify Physician and Follow Weight Monitoring Orders: Two residents had significant weight loss, but one resident’s physician was not notified after a 5.19% loss in one month, and another resident’s RD-recommended weekly weights for four weeks were not completed after an 11.8% loss in six months. Records showed the nutritional concerns, but the follow-up notification and ordered monitoring were not documented as completed.
GT Feeding Bag Not Labeled With Start Time: A resident receiving GT feeding had an enteral formula bag labeled with the date and rate, but the start time was not documented. An LPN stated the bag should be labeled with the resident’s name, date and time started, and infusion rate, and that enteral formulas should be discarded after 24 hours. The DON confirmed that nurses were expected to include the start date and time so the discard time could be determined.
A resident's peripheral IV dressing was observed without the date, time, or LPN initials, and the IV had not been discontinued even though it was no longer in use. Another resident still had a peripheral IV in place after IV antibiotic therapy ended, with no documentation that the physician was notified about continuing the access. Staff confirmed the unlabeled IV and the lack of documentation for the unused IV access.
Food Not Palatable or Appealing: Two residents reported that the food was not good, and during a meal tray observation the RD and MDS Coordinator found the orzo rice lacked flavor and had a mushy, too-soft texture, while the green beans were too soft. The Administrator and DON were informed and acknowledged the findings.
Failure to Provide Ordered Beverage at Lunch: A resident with ESRD on HD and a 1500 ml/day fluid restriction was observed eating lunch without the 120 ml of cranberry juice listed on the meal ticket. The resident stated she wanted her juice, and a CNA confirmed the beverage was not served. The DON and Administrator acknowledged the finding.
A facility failed to accurately document blood pressure access sites for two residents receiving hemodialysis. Both residents had AV shunts in the left arm and physician orders not to take BP or draw blood from that arm, yet multiple BP readings were charted as taken on the left arm. Staff later verified the documentation was inaccurate, and the DON confirmed the records did not match how the BPs were actually obtained.
Inaccurate Daily Nursing Staffing Postings: The facility failed to ensure daily nursing DHPPD postings were current and accurate. Surveyors observed posted staffing sheets that were dated earlier than the current day, and both RN 3 and the DON verified that the posted PPD information did not reflect the current staffing data required by policy. The DON acknowledged that the DSD was responsible for replacing the old projection each day.
A resident who was determined to have decision-making capacity received a written notice of proposed transfer and discharge to a board and care facility, citing improved health status and nonpayment as reasons. However, record review showed there was no physician order for discharge, no physician documentation that the resident’s condition had improved or that discharge was safe, and the post-discharge plan of care and summary were incomplete from nursing and social services. An RN confirmed that facility policy requires a physician discharge order and a completed IDT post-discharge plan prior to discharge, and verified these elements were missing.
A resident with severe cognitive impairment and documented nonverbal status had multiple nursing progress notes and skilled nursing evaluations indicating they were alert and oriented x3, verbally communicative with clear speech, able to follow commands, and denying pain or neurological symptoms, which conflicted with the physician note and MDS. Nursing notes also documented GT feeding, wound vac care, and IV antibiotics after the resident had been discharged to the hospital. During interview and record review, the DON acknowledged significant confusion and inaccuracies in the nursing documentation and questioned whether nurses were actually assessing the resident or copying and pasting entries.
A resident was admitted with severe cognitive impairment and multiple documented pressure injuries and other wounds, but no baseline wound care plan was developed within 48 hours of admission despite facility policy and staff expectations that each wound have its own care plan and specific interventions. The same resident had physician orders for NPO status and enteral tube feeding, supported by a swallowing evaluation and physician progress note, yet the nutritional care plan instead focused on honoring food preferences, offering meal substitutes, and allowing time to eat and drink, implying oral intake. The DON, IP, and an LVN all confirmed that the wound care plan was missing and that the nutritional care plan did not reflect the resident’s NPO and enteral feeding orders, and the DON stated this incorrect plan could have led to oral intake and aspiration.
A cognitively intact resident with an order to go out on therapeutic pass had multiple departures documented on a Release for Temporary Absence form, but many return times were illegible or missing. A social services note stated the resident went out daily for more than six hours, which conflicted with the incomplete sign-out/sign-in documentation. The resident, receptionist, SSD, and ADON all confirmed that the resident routinely signed out at reception, that some return times were not recorded, and that there was no consistent process to sign the resident back in when reception staff were no longer present, resulting in an inaccurate medical record.
A resident with CHF and hypotension, who lacked decision-making capacity, had an order for Midodrine 10 mg via GT every eight hours with instructions to hold the dose if SBP was greater than 100 mmHg. Facility policy required medications to be given per MD orders and to hold medications when vital signs were outside ordered parameters. Review of the MAR showed that staff repeatedly administered Midodrine despite SBP readings above 100 mmHg, and an RN later confirmed that the medication should not have been given under those conditions and that this could affect the resident’s health.
Surveyors found that the facility did not employ a qualified full-time social worker as required for a facility with more than 120 beds. The job description for the Social Services Director (SSD) required at least a bachelor’s degree in social work or another human services field plus one year of supervised social work experience in a health care setting. Review of the SSD’s file showed only a high school diploma and prior SSD experience in another nursing facility, and in an interview the SSD confirmed this was the highest level of education despite serving in the full-time SSD role for over two years.
A resident reported two separate incidents of verbal threats and intimidation by another resident with a history of schizophrenia and verbal aggression. Despite informing both an LVN and the DON, the facility's Administrator was not made aware of the allegations and did not initiate the required abuse investigation or reporting to the state agency, as mandated by facility policy. Another resident corroborated the threatening behavior, but the incidents were not properly addressed or documented.
A resident's personal belongings were not properly inventoried or documented upon admission, and the required signature was not obtained, despite the resident's capacity to sign. Later, the resident reported missing money from a wallet that was sent to the laundry, and the missing items were not listed on the belongings form. Staff confirmed the documentation was incomplete and did not follow facility policy.
A resident was discharged without the required physician documentation indicating that their health had improved sufficiently and that they no longer needed facility services. The medical record did not show that the physician assessed the resident for a safe discharge prior to the planned discharge date, as required by facility policy.
Surveyors identified that three ice machines were not maintained in sanitary working condition, with visible residues and stains on internal components and storage bins. The facility also failed to follow manufacturer cleaning specifications, as a generic cleaner was used instead of the recommended product. These deficiencies had the potential to affect 145 residents receiving oral diets.
Surveyors found that the facility did not consistently complete or document required bed entrapment assessments for several residents using bed rails or grab bars. In multiple cases, the necessary measurement for Zone 7 was missing from maintenance records, and some worksheets lacked clear units of measurement. Facility staff, including the Maintenance Director, acknowledged these documentation gaps, which were observed during resident care and record reviews.
Delayed Response to Call Lights and Resident Assistance
Penalty
Summary
The facility failed to reasonably accommodate residents’ needs and preferences when call lights were not answered in a timely manner for two residents. One resident, who had moderate cognitive impairment and was dependent on toileting hygiene, was observed lying in bed with a diaper after having a bowel movement. The resident’s family member stated they had been waiting more than 20 minutes for help to clean the resident and reported this was a frequent occurrence, including at night when the resident reportedly waited 45 minutes to an hour for assistance and had to press the call light repeatedly before getting help. During the observation, the call light for that room was on and no staff were seen responding for an extended period. The family member went to the nurses’ station and was told the assigned staff would be called. A CNA later entered the room after being informed the resident needed to be cleaned. The resident stated she felt dirty because she had been sitting in her stool. A second resident, who had intact cognition and needed substantial to maximal assistance with upper body dressing and dependent assistance with lower body dressing, was observed waiting for help after spilling liquid on her shirt sleeve and wanting to change clothes. The resident stated she had been waiting since 1400 hours and was upset. The room call light was on with no staff initially responding, and the resident was later assisted after a CNA entered the room. An LVN stated she did not notice the call lights while passing medications, and a CNA stated the CNAs were responsible for answering call lights but had been very busy.
Failure to Protect Resident from Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident’s right to be free from verbal abuse by another resident. The deficiency involved Resident 5, who had a history of stroke and expressive aphasia and was documented as having the capacity to make her own decisions. During the incident, Resident 5 was sitting near the nurses’ station when Resident 2, who had been admitted with the capacity to understand and make decisions and was being monitored on 1:1 observation for inappropriate wandering and indecent exposure, became involved in a verbal altercation with her. Facility documentation and staff interviews showed that Resident 2 used derogatory and insulting language toward Resident 5, including mocking the resident’s slurred speech and making gender-based comments. The progress note documented that Resident 2 called the resident derogatory names and made fun of the way she spoke. LVN 1 stated she heard Resident 2 say, “stupid bitch,” and mock Resident 5’s speech because of her stroke. CNA 1 also described Resident 2 telling Resident 5 to “shut the fuck up” and saying he would not go easy on her because she was a girl. Both staff members identified the interaction as verbal abuse. Resident 5 later stated that she remembered a male resident cursing at her near the nurses’ station and insulting her because of the way she spoke. She said the comments made her angry and upset. RN 3 confirmed he heard the verbal interaction between the two residents, but stated he did not consider it verbal abuse. The facility’s investigation summary stated the comments were rude but were not received in a manner that frightened, intimidated, or threatened Resident 5, and the facility was unable to substantiate the alleged abuse occurred.
Failure to Timely Report Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its policy for reporting suspected abuse when a resident-to-resident verbal altercation occurred involving Resident 2 and Resident 5. The facility policy required allegations of abuse, neglect, exploitation, or mistreatment to be reported immediately to the Administrator and to appropriate agencies within required timeframes, including notification of the state agency, ombudsman, and law enforcement when suspicion of abuse occurred. Resident 2 was on 1:1 observation for indecent exposure and was being followed by a CNA when he became aggressive, pushed the CNA, and then engaged in a verbal altercation with Resident 5 near the nursing station. According to the nursing progress note and staff interviews, Resident 2 used derogatory and threatening language toward Resident 5, including statements mocking her speech and gender-based insults. Staff who witnessed the event included the CNA, the charge nurse, and the RN supervisor, and the CNA stated he believed the interaction was verbal abuse. Although staff were aware of the incident, the Administrator stated he was not informed at the time, and the abuse allegation was not reported to CDPH L&C, the ombudsman, or law enforcement until 19 days later. The DON and RN 3 both stated that resident-to-resident altercations should be reported promptly after the residents are made safe, but the facility did not timely report the allegation that occurred between Resident 2 and Resident 5.
Failure to Timely Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse investigation policy when a resident-to-resident verbal altercation involving derogatory language was not immediately investigated. The facility policy required all alleged violations to be investigated, residents to be protected during the investigation, and reporting to occur according to facility procedure. The incident involved Resident 2, who had been admitted with the capacity to understand and make decisions, and Resident 5, who had a history of stroke and expressive aphasia and also had the capacity to make her own decisions. According to the medical record and staff interviews, on 6/28/26 Resident 2 was on 1:1 observation for indecent exposure when he pushed a CNA, stated he did not want to be followed, and then engaged in a verbal altercation with Resident 5 near the nursing station. The progress note documented that Resident 2 told Resident 5 he was not going to go easy on her because she was a girl, called her derogatory names, and mocked the way she spoke. LVN 1 later confirmed she witnessed Resident 2 use abusive and mocking language toward Resident 5, and stated the RN supervisor was also present and heard the interaction. The Administrator stated he was not informed of the incident at the time it occurred and only learned of it later when the surveyor identified the documentation. The facility’s SOC 341 showed the abuse allegation was not reported to CDPH, L&C Department until 19 days after the event. RN 3 and the DON both stated that resident-to-resident altercations should be reported right away and that the SOC should be started immediately, but the DON verified the alleged verbal altercation was not investigated in a timely manner.
Failure to Care Plan After Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident 5 after an alleged verbal abuse incident involving Resident 2. Facility policy required identification, ongoing assessment, care planning, and monitoring of residents with needs and behaviors that might lead to conflict or neglect, and also required revision of the resident’s care plan if medical, nursing, physical, mental, or psychosocial needs changed as a result of abuse. However, the resident’s plan of care, with initiation dates from 5/8 to 7/21/26, did not show a care plan problem was initiated when Resident 5 was allegedly verbally abused by Resident 2. Resident 5 had a history of stroke and expressive aphasia and was noted to have the capacity to make own decisions. The MDS showed no behavioral symptoms directed toward others. A progress note in Resident 2’s chart documented a verbal altercation in which Resident 2 used derogatory language toward Resident 5. During interview, Resident 5 recalled that a male resident cursed at her and insulted her because of the way she spoke, stating it made her angry and upset, though she later said she was no longer bothered because Resident 2 was no longer in the facility. RN 2 and the DON both stated that a new identified problem should result in a care plan being initiated or revised, and RN 2 verified that no care plan had been initiated for the incident.
Care Plan Not Revised After Resident’s Verbal Altercation
Penalty
Summary
The facility failed to revise Resident 2’s comprehensive care plan after an incident in which the resident used derogatory language toward another resident. Resident 2 was admitted to the facility and had an H&P dated 3/7/26 showing the resident had the capacity to understand and make decisions. A nurses progress note dated 6/28/26 documented that Resident 2 had been on 1:1 supervision for indecent exposure, was observed going into another room, pushed a CNA when redirected, and stated he would punch the CNA the next time he followed him around. The same note documented that Resident 2 then became involved in a verbal altercation with another resident, telling her, “I’m not going to go easy on you because you are a girl, you picked the wrong guy,” and then calling her multiple derogatory words and mocking the way she spoke. The resident already had a behavior care plan initiated on 6/19/26, but the care plan was not revised to reflect the 6/28/26 incident. RN 2 confirmed the care plan did not reflect the resident’s behavior toward the other resident, and the DON stated that any new focus or problem should result in a revised care plan.
Late Medication Administration and Incomplete Controlled Drug Sign-Offs
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure timely and accurate medication administration for three sampled residents and failed to ensure controlled drugs on one medication cart were signed off by two licensed nurse witnesses. The report states that Resident 1 did not receive the prescribed amlodipine on 7/6/26, and that medications due at 0900 hours were administered late to Residents 1, 3, and 4 by LVN 4. The facility’s medication administration policy required medications to be administered within 60 minutes before or after the scheduled time unless otherwise ordered, and the controlled substance policy required two licensed staff to witness disposal or destruction and document it. Resident 1 had orders for ferrous sulfate, Januvia, multivitamin-minerals, cyanocobalamin, alprazolam, and amlodipine besylate 7.5 mg daily for hypertension with instructions to hold for SBP below 110 or HR below 60. The MAR for 7/6/26 showed the amlodipine box blank, and the record did not show why it was not given at the scheduled 0630 time. During interview, one LVN stated the medication was not signed off and that a blank box could mean nothing was done or the medication was not given, while another LVN stated the resident was still sleeping and the medication had not yet been given at the end of the shift. On 7/15/26, Resident 1 stated the morning medications were too late, and the eMAR showed several 0900 medications documented at 1107 and 1108 hours. Resident 3 had an order for methadone hydrochloride oral concentrate 10 mg/ml daily for pain management, and the eMAR showed it scheduled for 0900 hours and documented at 1009 hours. Resident 4 had orders for calcium with D3, Eliquis, famotidine, cholecalciferol, and polyethylene glycol, all scheduled for 0900 hours, and the eMAR showed them documented at 1015 hours. LVN 4 stated he received Medication Cart A at 1000 hours, had nine residents to pass medications for that cart, and gave the medications after receiving the cart. For controlled drugs, Medication Cart A’s count record for 7/14/26 and 7/15/26 showed missing signatures for the incoming and outgoing licensed nurses on the 0700-1500 and 1500-2300 shifts, and the CII Ekit Serial # column was blank on some entries. Staff interviews confirmed that the controlled drug count was expected to be completed and signed by both the incoming and outgoing charge nurses together.
Medication Administration Not Timely for Resident With Chronic Pain
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when medications were not administered as ordered for one sampled resident. Resident 4 was admitted with diagnoses including chronic pain syndrome. The resident had orders for Pregabalin 50 mg by mouth three times daily for chronic pain, Buprenorphine HCl 2 mg sublingually three times daily for pain management, and Gabapentin 600 mg by mouth three times daily for neuropathy, with all three medications scheduled for 0400, 1200, and 2000 hours. Review of the June 2026 MAR and Administration Details showed that on 6/12/26, Pregabalin was given at 0602, Buprenorphine HCl at 0600, and Gabapentin at 0601, instead of the scheduled 0400 administration time. Facility policy stated medications must be administered within one hour of the scheduled time. During an interview and concurrent record review with the DON, the DON verified the findings and confirmed the medications were not administered in accordance with the provider's order and facility policy.
Care Plan Not Updated for Diabetes Management Change
Penalty
Summary
The facility failed to revise Resident 7’s care plan to reflect changes in diabetes management after the resident’s insulin was discontinued. Resident 7 was admitted and later readmitted with a diagnosis of diabetes, and the care plan on record still addressed Insulin Glargine, Insulin Lispro per sliding scale, and Metformin HCl for diabetes management. A nursing progress note documented that all insulin was discontinued with alternative glucose management in place, but the care plan was not updated to match the physician’s order. During an interview and concurrent record review, an LVN verified that the care plan should have been revised to reflect the resident’s current diabetes interventions.
Unattended Medicated Creams Left at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were stored in a safe manner for one of ten sampled residents, Resident 10. During an observation and concurrent interview in the resident’s room on 5/6/26 at 1508 hours, two medication cups containing medicated cream were found left on the resident’s bedside table, each with a tongue depressor labeled for use on the arms and back. Resident 10 stated he was waiting for the Treatment Nurse to apply the creams to the affected areas. Review of the medical record showed Resident 10 had physician’s orders dated 4/13/26 for Nystatin external cream 100000 Unit/gm to the back every day shift for tinea corpus and Triamcinolone Acetonide external cream 0.1% to the arms every day shift for psoriasis until finished. At 1511 hours, Treatment Nurse 1 stated she was waiting to coordinate with the CNA during brief change to apply the medicated cream and confirmed the creams should not be left unattended. The facility’s Medication Storage policy stated medications must be stored in the pharmacy and/or medication rooms according to manufacturer recommendations and, during a medication pass, must be under the direct observation of the person administering medications or locked in the medication storage area/cart.
Unsafe Transfer and Improper Storage of Smoking Materials
Penalty
Summary
The facility failed to ensure Resident 179 was safely transferred from bed to wheelchair. Resident 179 had a BIMS score of 14 and care plan interventions addressing impaired mobility, fall risk, and potential for skin tears, including caution during transfers and bed mobility to avoid striking arms, legs, and hands against hard or sharp surfaces. The facility’s Safe Resident Handling/Transfers policy stated that all residents require safe handling when transferred to prevent or minimize injury. On 4/1/26, Resident 179 sustained an injury during a transfer from bed to wheelchair. Nursing documentation noted a skin tear to the right shin during the transfer, and later documentation described a skin tear with moderate bleeding and a hematoma. A physician progress note stated that while transferring Resident 179 into the wheelchair, her leg got stuck or caught in the wheelchair, causing a large 10-cm abrasion and large hematoma on the right anterior shin. Resident 179 reported that RNA 1 transferred her without using a gait belt, that her leg hit the metal on the front of the wheelchair where the footrest would attach, and that she yelled for the transfer to stop but the staff member could not control the momentum. RNA 1 stated she independently transferred Resident 179 from bed to wheelchair and did not use a gait belt. She stated she was not informed that Resident 179 needed a gait belt and was not familiar with the resident, having cared for her only twice. The Director of Rehabilitation reviewed therapy documentation showing Resident 179 required substantial/maximal assistance for transfers, and stated the facility protocol was to always use a gait belt when independently transferring residents from bed to wheelchair. The DON stated the facility’s investigation concluded that RNA 1 failed to secure Resident 179 during the transfer and should have used a gait belt to stabilize her. The facility also failed to ensure Resident 74’s cigarettes and cigarette lighters were stored safely in accordance with the Resident Smoking policy. Resident 74 had decision-making capacity and was assessed as able to smoke with supervision, but the smoking assessment did not address safe storage of smoking materials. During observations, an open package of cigarettes and two cigarette lighters were found within reach on the overbed table at the resident’s bedside on multiple occasions. Staff members observed the lighters and removed them, and an RN stated the resident should not have cigarettes and cigarette lighters at bedside. The Administrator and DON were informed of the bedside smoking materials and acknowledged the findings.
Medication Labeling, Storage, and Disposal Deficiencies
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmacy services related to medication labeling, storage, and disposal. Facility policy required prescription medications to be labeled with the resident’s name and other key information, and nonprescription medications to remain in the manufacturer’s container and identified with the resident’s name. During inspection of a medication cart, surveyors found 22 packets of 5% lidocaine patches rubber-banded together with no pharmacy label or resident identification. The LVN assigned to the cart stated that two residents had orders for lidocaine patches and that someone must have removed the packets from the manufacturer’s box, confirming there was no label to indicate which residents the packets belonged to. The DON and the consultant pharmacist both confirmed that non–over-the-counter medications should have resident labels and that the labeled box and packets should not have been separated. The facility also failed to ensure expired and beyond-use-date medications were separated and removed from active stock as required by its policy on discontinued medications. In one medication room, surveyors observed a manufacturer box of ferrous gluconate 325 mg unit-dose tablets on the shelf with a manufacturer expiration date that had already passed; the RN present verified the medication was expired and should not have been on the shelf. On multiple medication carts, surveyors found expired blister packs of cyclobenzaprine and clonidine with past expiration dates still stored with active medications; the LVNs confirmed these medications were expired and should have been removed for destruction. Additionally, two Lantus Solostar insulin pens on a cart were found with open dates indicating they had been in use longer than the 28 days specified on the pharmacy label and manufacturer information, and the LVN confirmed both pens were expired but still present on the cart. Further deficiencies were identified in the labeling and handling of multi-dose injectable vials and insulin pens. Facility policy required multi-dose vials to be labeled with the date opened and initials of the first user. In a medication room refrigerator, surveyors observed a multi-dose vial of cyanocobalamin with the protective cap removed, visibly used, but without an open date; the RN confirmed an open date should have been on the vial. On a medication cart, a Novolog insulin pen stored at room temperature had no open date, and on another cart, Lantus and Humalog insulin pens also lacked open dates on the pens or pharmacy labels; the LVNs acknowledged that staff needed to enter the open dates. The consultant pharmacist stated that the time period for insulin pen use begins when the pens are removed from the refrigerator, underscoring that open dating was required but not done. Surveyors also found that medications were not properly stored at the bedside for two residents. One resident, who was cognitively able to follow commands and answer appropriately per a prior H&P, had a container of antacid tablets from home on the overbed table, with about one-third of the tablets remaining. When asked, the resident stated she took them when needed and did not want to bother staff. Review of the MAR showed PRN orders for calcium carbonate and simethicone, but these medications were not documented as administered. An LVN and an RN both acknowledged that the antacid container should not have been on the overbed table, and the resident became upset when the LVN attempted to remove it. In another case, a resident who was documented as unable to make decisions had a three-quarters full bottle of povidone-iodine on the overbed table while a family member was present. The resident had physician orders for povidone-iodine treatment to bilateral heel DTIs. Nursing staff confirmed the bottle’s presence on the overbed table and stated that no medications should be at bedside, noting that family sometimes placed items there.
Respiratory equipment and oxygen care not maintained or ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for multiple residents who were receiving oxygen, CPAP, or nebulizer treatments. During an initial tour, Resident 2 was observed lying in bed on ventilator support via tracheostomy, and the oxygen concentrator filter at the bedside was covered with dust-like particles. Resident 11 was also observed with oxygen in progress via tracheostomy, and the oxygen concentrator filter at the bedside was likewise covered with dust-like particles. An LVN and an RT both verified that the filters were dirty, and the RT stated the filters were supposed to be clean. Resident 31’s nebulizer mask was observed at the bedside inside a clear storage bag and labeled with a date of 2/16. The resident had an order for ipratropium-albuterol inhalation solution as needed for shortness of breath or wheezing. During the observation, an LVN stated the nebulizer masks should be changed weekly and then discarded the mask and tubing. Resident 14’s nebulizer tubing was observed on the nightstand in a plastic bag without a name or date. The resident had orders for albuterol inhalation solution four times daily and acetylcysteine inhalation solution four times daily for respiratory symptoms and mucus secretion. The IP verified the tubing was in a bag with no name or date and stated the tubing was to be changed weekly and labeled when changed. Resident 20 was observed receiving oxygen at 4 liters per minute via nasal cannula, although the record showed an order for oxygen at 2 liters per minute every shift and another order allowing titration up to 5 liters per minute to maintain oxygen saturation at or above 92%. Staff verified the resident was on 4 liters per minute and stated the oxygen had not been titrated that morning. The resident’s oxygen saturation was documented at 95%, and the MAR did not show titration documentation. The same resident was also observed with CPAP tubing and headgear in a plastic bag dated 4/13, while the resident stated the CPAP was used at night and did not see the tubing and headgear cleaned the prior day. RN 3 verified the tubing and headgear should have been cleaned and dated. Resident 72 was observed receiving continuous oxygen at 4 liters per minute via nasal cannula, but no oxygen warning sign was posted on the room door. The medical record did not show a physician’s order for continuous oxygen therapy via nasal cannula, and the care plan did not show a problem developed for the resident’s oxygen use. An LVN verified the resident was receiving continuous oxygen, confirmed the missing warning sign, and verified there was no physician’s order. The DON later stated that continuous oxygen therapy should have a physician’s order and a care plan problem, and that oxygen tubing, including the nasal cannula and nebulizer mask, should be changed weekly.
PRN Narcotic Pain Medications Given Outside Ordered Parameters
Penalty
Summary
The facility failed to provide appropriate pain management for two residents who had physician-ordered PRN narcotic pain medications. Facility policy stated that pain interventions were to be developed, implemented, monitored, and revised based on pain evaluation, and that pharmacological interventions were to follow a systematic approach for selecting medications and doses to treat pain. Resident 17, who was admitted to the facility and was able to understand and make treatment decisions, reported generalized body pain and back pain that was usually 10 out of 10. Her orders required oxycodone 5 mg PRN for moderate to severe pain, with nonpharmacological interventions attempted first and documented, including whether they were effective or ineffective. Review of Resident 17’s MAR showed oxycodone was administered on multiple occasions when the documented pain levels were 0 or 3, and the record did not reflect the ordered nonpharmacological interventions as required. Resident 20, who had a BIMS score of 15 indicating intact cognitive capacity, had an order for hydrocodone-acetaminophen 5-325 mg PRN for moderate to severe pain with the same required nonpharmacological interventions and documentation. The MAR showed the medication was given when the pain level was 3, which was below the ordered pain parameter of 4 to 10. During interviews, nursing staff acknowledged that Resident 17’s oxycodone was not administered as ordered and that Resident 20 should not have received hydrocodone-acetaminophen for a pain level of 3.
Incomplete dialysis communication and missing bedside emergency kits
Penalty
Summary
The facility failed to provide safe, appropriate hemodialysis care and services for multiple residents receiving dialysis. The report states that the facility did not ensure a hemodialysis emergency kit was available at the bedside for Residents 14, 26, 39, and 97. Resident 39 had a right upper chest perma-catheter and Resident 97 had an AV shunt in the left arm; both stated they went to hemodialysis on Tuesdays, Thursdays, and Saturdays. Resident 14 had a right thigh perma-catheter and Resident 26 had a right upper chest perma-catheter. Staff confirmed that the emergency kit should have been available at the bedside for use if bleeding occurred at the dialysis access site. For Resident 41, the dialysis communication record was incomplete and the hemodialysis center’s recommendation to hold metoprolol on dialysis days was not followed as documented. The record showed missing post-dialysis assessments, missing access-site documentation, and missing post-dialysis weights on multiple dialysis communication forms. The hemodialysis center documented that blood pressure medications should not be given on dialysis days to prevent hypotension, and later documented to hold metoprolol, iron, and ESA on a dialysis day; however, the MAR showed metoprolol was administered that morning. The medical record did not show that the center’s recommendations were communicated to the physician on those days. The record also failed to show nursing documentation of monitoring the dialysis access site, even though the care plan addressed access-site monitoring. For Resident 49, the dialysis communication forms were incomplete and inaccurate, with multiple missing post-dialysis assessments, missing vital signs, missing access-site documentation, and missing nurse signatures. The resident had ESRD and received hemodialysis three times weekly. The resident was also on a 1500 mL/day fluid restriction with orders to record intake and output. During observation, a water pitcher was present at the bedside without graduated measurement, and staff stated the resident was on fluid restriction and should not have a water pitcher at bedside. The record also showed intake and output was not recorded on several dates, and staff stated the resident drank from the pitcher and from meal trays. For Resident 72, the dialysis communication record was also incomplete and inaccurate, with missing dialysis end times and missing or inconsistent documentation of catheter location/status and post-dialysis assessments on several forms.
Medication Administration Errors and GT Medication Mixing
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent after surveyors observed medication administration for three residents and identified a 12.5% error rate. For one resident with hypertension, the morning dose of amlodipine 7.5 mg was prepared but not administered because the medication was not available at the time of the observation. The resident’s MAR showed the dose was documented as not given and later administered at 1846 hours. The physician’s order for daily amlodipine was dated 4/20/26, and the MAR scheduled the dose for 0900 hours. For another resident, the morning doses of apixaban 2.5 mg and metoprolol 25 mg were prepared but not administered because the medications were not available. The MAR showed two doses of apixaban and one morning dose of metoprolol were documented as not given. Progress notes showed the pharmacy was contacted later and stated apixaban was already being worked on and metoprolol had to be reordered because the prior reorder did not go through. During interview, the nurse stated the pharmacy had not yet been contacted at the time the medications were unavailable. For a third resident with a GT, the nurse prepared finasteride 5 mg, calcium carbonate 500 mg, docusate 50 mg/5 mL, and polyethylene glycol 3350 17 grams, crushed or measured them, mixed all four medications in approximately four ounces of water, and administered them together through the GT. Facility policy and cited guidance required each medication to be administered separately with flushing between medications. The DON and consultant pharmacist acknowledged that the medications via GT needed to be given one at a time, and there was no documentation supporting administration of all medications together with minimal water.
Menu Not Followed and Alternative Meal Not Offered
Penalty
Summary
The facility failed to ensure the menu was followed when residents were served pork cutlet with an orange-colored sweet glaze instead of the sour cream sauce listed on the menu for the lunch meal. During trayline observation, the pork cutlet was seen with the glaze rather than the planned sauce. The cook stated he could not find sour cream while preparing the sauce and made the sweet glaze instead, and he did not inform DSS of the substitution. DSS stated the menu should be followed and that if items were unavailable, the cook should notify DSS so the menu could be updated and residents informed of the change. The facility also failed to offer an alternative menu to Resident 54 when he refused breakfast and lunch. Resident 54 was admitted and readmitted to the facility and had an H&P dated 12/7/25 showing he had the capacity to understand and make decisions. On 4/21/26, his nutrition record showed he refused both meals. During observation, he stated he returned his lunch tray because he did not like potatoes and beans and said he was not offered an alternative menu. RN 2 stated a substitution order form should be completed and sent to the kitchen, but the form could not be found and there was no documentation in the resident's medical record. CNA 1 stated she did not remember offering an alternative menu or completing the substitution form.
Pureed Diet Foods Served in Runny Consistency
Penalty
Summary
The facility failed to ensure dietary texture guidelines were followed for 22 residents who were ordered a pureed texture diet. During a lunch tray line observation, Resident 140’s meal ticket showed a pureed thin liquid diet, and the tray included pureed pork with orange sauce, pureed bread, pureed green beans, and pureed orzo rice. The pureed pork, beans, rice, and bread were observed to be runny, not holding their shape, and touching the surrounding entrees. Review of the facility’s Diet Type Report dated 4/20/26 showed 22 of 155 residents who received food prepared in the kitchen were on a pureed texture diet. The facility’s P&P for Puree Food Preparation stated pureed foods should be prepared to conserve nutritive value, palatable flavor, and attractive appearance, and should prevent lumps or chunks with a smooth, soft, homogenous consistency similar to mashed potatoes. The RD verified the tray findings and stated pureed entrees should hold their shape and that food prepared too watery may lead to aspiration. The RD stopped the tray line and asked the cook to make the puree items thicker. The Administrator and DON were informed and acknowledged the findings.
Kitchen Food Safety, Labeling, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met in the kitchen. During an initial kitchen tour with DSS 1, surveyors observed multiple food items that were not properly labeled, including two ham sandwiches in Refrigerator A without a preparation or use-by date, two boxes of mighty shakes in Refrigerator B without the date they were placed in the refrigerator, and an orange juice box connected to the juice dispenser without an opened date. DSS 1 confirmed the findings and stated the items should have been labeled with use-by or opened dates when placed in storage or connected to the dispenser. Surveyors also observed multiple kitchen utensils and equipment that were not kept in sanitary condition. The metal racks holding plastic trays in Refrigerator A had dry yellow residue and multiple dry white particles, and several food preparation items had visible residue, including a black blender lid, detachable blender blade, gray blender, white brush, black plastic serving spoon, slotted portion server, and yellow handle scooper. The stationary can opener had a brownish fuzzy substance, and two sheet pans had brownish-black stains. DSS 1 verified these observations and stated the food preparation equipment should be clean. In addition, surveyors found utensils that were not in good condition and food items past their use-by or best-by dates. Observed items included two chipped spatulas, a white spatula with brownish discoloration, and a metal spatula with a melted handle. Nine 16-oz bags of Splenda had a use-by date of 10/25/25, six cans of vanilla pudding in the emergency food supply had a best-by date of 11/10/25, and one box of iced tea connected to the juice dispenser had a best-by date of 2/20/26. The Administrator and DON were informed and acknowledged the findings.
Infection surveillance and infection control practices were not maintained
Penalty
Summary
The facility failed to establish and maintain an infection control program and practices designed to help prevent the development and transmission of diseases and infections. The infection surveillance process for January through April 2026 was conducted only for residents who had signs and symptoms of infection and were prescribed antimicrobial medications. The infection preventionist stated that residents with signs and symptoms of infection who were not prescribed antibiotics were not included on the surveillance list, and residents with Candida Auris were considered colonized and were not included. The facility’s monthly surveillance reports documented infections, but the report did not consistently show the type of infection or whether the infection met McGeer’s criteria, and for April 2026 there was no documentation showing whether 21 residents with infections met the criteria of a true infection. For one resident with chest congestion, cough, shortness of breath, and fever, the infection screening evaluation did not show whether Loeb’s or McGeer’s criteria were met. The facility also failed to maintain infection control practices related to enteral feeding equipment and respiratory equipment. During observations, the tube feeding pumps for four residents were found with dust-like particles and dried formula on the pump surfaces and connector areas. One resident’s GT syringe was observed hanging on the GT pole with whitish remnants at the tip and brownish to blackish fluid in the bag, and staff confirmed that GT syringes were to be changed daily. Another resident’s respiratory suction machine was observed placed directly on the floor. A blanket used to cover a resident after a shower was taken from the top of a soiled linen cart and then used on the resident. These events were observed and confirmed by staff during the survey. The facility further failed to follow its enhanced barrier precaution and water management practices. A CNA provided care to a resident on enhanced barrier precautions without wearing a gown, despite the resident having a GT and visible posting and PPE cart outside the room. Another resident with a GT had a care plan addressing enhanced barrier precautions, but the physician order summary did not show an order for enhanced barrier precaution. In addition, the facility’s water management program required investigation of healthcare-associated legionellosis and screening of pneumonia cases for possible Legionnaire’s disease, but the IP and DON stated that testing was done only if there was a case of legionnaires and that the facility would know a resident was positive only if tested in-house. The surveillance reports showed pneumonia cases from January through March 2026, but the facility did not document screening of pneumonia cases for possible Legionnaire’s disease.
Incomplete antibiotic stewardship infection assessments
Penalty
Summary
The facility failed to implement its antibiotic stewardship program when it did not conduct a complete assessment using McGeer’s criteria to determine whether the infections treated for two residents met the criteria for true infection. The facility’s policy stated that the Antibiotic Stewardship Program was part of the infection prevention and control program, with the Infection Preventionist and DON responsible for oversight. However, review of the monthly Infection Surveillance Reports for January through April 2026 showed that the reports did not completely indicate whether residents’ infections met or did not meet McGeer’s criteria, and the Infection Screening Evaluations in the medical records did not show all criteria used to assess for McGeer’s criteria. For one resident, the March 2026 surveillance report showed Vancomycin HCL IV was prescribed, but the report did not identify whether the infection treated was CAI or HAI, or whether McGeer’s criteria were met. The resident’s Infection Screening Evaluation dated 3/9/26 showed an active diagnosis of infection, but did not indicate whether Loeb’s or McGeer’s criteria were met. For the second resident, the April 2026 surveillance report showed Vancomycin HCL oral suspension was prescribed for C-difficile bacteria, but again did not show whether the infection treated was CAI or HAI, or whether McGeer’s criteria were met. During interview, the IP stated the diarrhea developed in the facility, but also stated uncertainty about where the CAI designation was on the report. The Administrator and DON were informed and acknowledged the findings.
Failure to Complete and Co-Sign Controlled Drug Count at Shift Change
Penalty
Summary
Surveyors identified that the facility failed to provide necessary pharmaceutical services to ensure accurate reconciliation of controlled medications for one of two medication carts reviewed. During an observation and concurrent record review of the Controlled Drugs - Count Record for April 2026 for Station C, Cart D, it was found that on 4/19/26 the lines designated for the “Nurse On 3-11 shift (PM shift)” and “Nurse Off 3-11 shift” were not signed. In an interview, a registered nurse confirmed the missing entries and stated that two licensed nurses’ signatures were required at change of shift to indicate that the controlled drug count had been completed at the end of the shift. In a separate interview, the DON stated that licensed nurses were expected to perform a narcotic drug count during change of shift and sign the Controlled Drugs - Count Record, and the DON and Administrator later acknowledged these findings. These failures were cited as not meeting the requirement to provide pharmaceutical services that ensure accurate controlled medication reconciliation and proper documentation by two licensed nurses during shift changes, with the report stating that these failures had the potential for inaccurate reconciliation and drug diversion of controlled medications.
Failure to Preserve Resident Dignity During Feeding and Catheter Care
Penalty
Summary
The facility failed to provide dignity and respect for Resident 123 during meal assistance. On 4/20/26 at 0830 hours, CNA 7 was observed standing over Resident 123 while feeding the resident, who was sitting in a reclining chair. During the concurrent interview, CNA 7 verified that he was standing over the resident while feeding and stated he was standing because there was no chair and no space beside the resident. CNA 7 also stated he should be sitting in a chair when feeding Resident 123. The DON later stated that CNAs were expected to sit when feeding residents. The facility also failed to provide a privacy bag for Resident 203's indwelling urinary catheter drainage bag. Resident 203 had been admitted and readmitted to the facility, and the H&P dated 3/3/26 documented that the resident had the capacity to understand and make decisions. The MDS showed obstructive uropathy and an indwelling urinary catheter. During observation on 4/20/26 at 0750 hours, Resident 203 was in bed while CNA 13 assisted with breakfast, and the urinary drainage bag containing yellow urine was hanging on the left side of the bed without a privacy cover and visible from the doorway. CNA 13 verified that the drainage bag did not have a privacy cover and could be seen from the doorway, and RN 3 stated that residents with an indwelling urinary catheter attached to a drainage bag should be provided with a drainage privacy bag to provide dignity.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure that Resident 159 or the resident’s responsible party was fully informed and that informed consent was obtained before the use of psychotropic medications. Resident 159 was admitted and later readmitted to the facility, and the H&P dated 8/20/25 stated the resident had no capacity to understand and make decisions. The resident’s physician orders included Depakote delayed release 125 mg via GT twice daily for mood stabilizer, escitalopram oxalate 10 mg via GT at bedtime for depression, and olanzapine 2.5 mg via GT daily for psychosis, with nonpharmacologic interventions listed to be tried before medication administration. Review of the Psychotherapeutic Drug Informed Consent Form for escitalopram showed it was undated and missing the psychotherapeutic drug information for caution and warning summary, the prescriber signature date, the resident or resident representative signature, and the licensed nurse signature. The informed consent form for olanzapine was dated 1/26/26 but was missing the psychotherapeutic drug information for probable side effects and significant risks associated with use of the medication and reasonable alternative modes of treatment or possible nonpharmacologic approaches, as well as the prescriber signature name and date and the resident or resident representative signature. The informed consent form for Depakote was also dated 1/26/26 and was missing the psychotherapeutic drug information for probable side effects and significant risks associated with use of the medication and reasonable alternative modes of treatment or possible nonpharmacologic approaches, along with the prescriber signature name and date and the resident or resident representative signature. The MAR showed escitalopram, Depakote, and olanzapine were administered in April 2026. During interview and concurrent record review, RN 3 verified the resident received the psychotherapeutic medications and confirmed the informed consent forms were incomplete. RN 3 stated the informed consent should contain complete information to educate the resident or responsible party of the treatment for their rights to be informed. The DON was later interviewed and stated the informed consents should be complete and accurate, and acknowledged the findings.
Unsafe Self-Administration and Bedside Storage of Medications
Penalty
Summary
The facility failed to ensure medications were safely administered to two residents when self-administration and bedside storage were not supported by physician orders or the residents’ medication administration assessments. The facility’s policy stated that a resident may only self-administer medications after the interdisciplinary team determines which medications may be safely self-administered, and bedside storage requires that access by other residents be prevented and that medications remain in the pharmacy-dispensed containers. Resident 54 was observed with an Albuterol HFA inhaler at the bedside and stated he used it for allergies and had last used it the night before. RN verification and record review showed there was no physician’s order for Resident 54 to self-administer the inhaler, and the self-administration assessment indicated he needed assistance with medications by various routes and preferred that the licensed nurse provide all medication administrations. Resident 20, who had a BIMS score of 15 indicating intact cognitive capacity, was observed with Blink geltears eye drops, GeriCare artificial tears eye drops, and Comfort Ear natural moisturizer ear drops on the bedside table. Resident 20 stated the nurse had left the drops for her to administer herself and that she forgot to return them that morning. LVN verification and record review showed there were no physician’s orders for these medications to be self-administered.
Missing Advance Directive in Resident Record
Penalty
Summary
The facility failed to obtain and maintain a copy of Resident 203’s advance directive in the medical record. Resident 203 was admitted and later readmitted to the facility, and the MDS assessment showed a BIMS score of 3, indicating severe cognitive impairment. The medical record included an Advance Directive Acknowledgement form dated 12/15/25 showing that Resident 203 had executed an advance directive, but review of the chart did not show a copy of the document. During a concurrent record review, the SSD stated that if the resident or responsible party acknowledged having an advance directive, a copy should be kept in the medical record, and verified that no copy was maintained. The DON was informed of the finding and acknowledged it.
Delayed physician notification of critical lab results
Penalty
Summary
The facility failed to ensure the physician was notified timely for Resident 41 after laboratory results showed critically low hemoglobin of 6.6 g/dL and critically low glucose of 49 mg/dL. The laboratory report was reviewed by LVN 8 at 1612 hours on 4/15/26, but the physician was not notified until 0200 hours on 4/16/26, more than nine hours later. When the physician was finally notified, an order was given to transfer Resident 41 to an acute care hospital for further evaluation and treatment. Resident 41 was admitted to the facility and later transferred to Hospital 2 on 4/16/26. The facility’s records showed the critically low hemoglobin was documented on the laboratory report, but Progress Notes did not show that the physician was informed between the time LVN 8 reviewed the report and the time the physician was notified. During interviews, LVN 8 stated she had been informed only of the low glucose result by RN 3 and later selected the report as reviewed, while the Laboratory Manager confirmed the facility had been informed of both critical values at 1542 hours on 4/15/26. RN 5 stated she identified the critically low hemoglobin during her shift on 4/16/26, saw it had not been addressed to the physician, and then notified the physician.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that one of six residents reviewed for unnecessary medications, Resident 17, was free from unnecessary psychotropic medication use. Resident 17 was admitted to the facility and, according to the H&P examination dated 2/22/26, was able to understand and make treatment decisions. The physician’s order summary showed an order dated 4/7/26 for lorazepam 0.5 mg, one tablet by mouth at bedtime for anxiety as manifested by restlessness and inability to relax. The facility’s policy stated psychotropic medications are to be used only when a practitioner determines the medication is appropriate for a resident’s specific, diagnosed, and documented condition and when the medication’s benefit is demonstrated by monitoring and documentation of the resident’s response. However, the order summary did not show a physician’s order for monitoring Resident 17’s restlessness and inability to relax related to lorazepam use. During interview and record review, LVN 10 stated residents receiving psychotropic medications were monitored every shift for the specific behaviors related to the medication, but she could not find documentation showing Resident 17 was monitored for restlessness and inability to relax. The DON stated residents receiving psychotropic medications should be monitored for the specific behaviors related to the medication to determine if it was effective.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to timely report an abuse allegation involving one resident after the Ombudsman and a family member reported that the resident stated a CNA had used a wooden stick or spoon and penetrated her body. The facility’s Abuse, Neglect, and Exploitation policy stated that all abuse allegations would be reported no later than 24 hours, and the cited regulation required reporting to CDPH, local law enforcement, and the long-term care ombudsman within 24 hours. The resident’s medical record included an eInteract SBAR summary documenting that she reported staff used a wooden object and inserted it into her anal and vaginal area. The record review did not show that the allegation was reported to CDPH, local law enforcement, or the Ombudsman. During interviews, the Ombudsman stated the resident and her family member had reported that a CNA took the resident to a dark room, forced her onto a table on all fours, and inserted a wooden spoon into her posterior while she screamed and fought back. The Ombudsman also stated the family member had reported the allegation months earlier, and the resident said the facility never followed up with her about it and that the CNA continued to work with her. The Administrator stated the facility identified the CNA involved but could not find records showing the allegation had been reported when staff became aware of it.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to timely investigate an abuse allegation involving Resident 12 after the Ombudsman and Family Member 1 reported that the resident stated a CNA used a wooden stick or spoon to penetrate her body. The facility’s Abuse, Neglect, and Exploitation policy required immediate investigation of all abuse reports to determine whether abuse or mistreatment occurred and the extent of it, but the Administrator was unable to find records showing the allegation was investigated when it was first reported in August 2025. Facility records showed Resident 12 later reported to providers that staff used a wooden object and inserted it into her anal and vaginal area. The resident’s care plan also noted behavioral problems related to bipolar disorder and statements indicative of delusional thinking and unfounded accusations. During interviews, the Ombudsman stated the resident and Family Member 1 had reported the allegation to the previous Administrator, and Resident 12 stated no one ever followed up with her about it and that the CNA continued to care for her after the report.
PASRR Screening Not Completed Before Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed before Resident 10 was admitted to the facility. Resident 10 was admitted from Hospital 1 on 3/9/26, and the hospital H&P dated 2/27/26 documented a past medical history of depression and psychoactive substance abuse. Review of the medical record did not show documentation that a PASRR Level 1 screening had been performed prior to admission. During an interview and concurrent record review on 4/21/26, the MDS Coordinator verified that the PASRR Level 1 screening had not been completed before the resident's admission and stated the facility would conduct the screening to determine whether the resident was screened for serious mental illness, intellectual disability, developmental disability, or related conditions.
Incomplete wound documentation, hospice coordination, insulin site rotation, and post-fall monitoring
Penalty
Summary
The facility failed to obtain and document measurements for a wound sustained by a resident during a staff-assisted transfer from bed to wheelchair. The resident sustained an abrasion and large hematoma on the right anterior shin when the leg became caught on the wheelchair during transfer. The resident stated the transfer was done without a gait belt and that the injury caused bleeding and significant pain. The resident also stated the leg remained swollen and had not fully healed at the time of observation. The licensed nurse documented an initial skin assessment and weekly skin checks after the injury, but the records for the initial assessment and the weekly assessments did not include wound measurements. The treatment nurse verified that the wound assessments were completed on the skin check forms, but also confirmed that no measurements were taken on the initial assessment or on the weekly assessments. The Director of Nursing reviewed the record and verified that the skin check forms and the change of condition assessment failed to show wound measurements. The facility also failed to conduct and document quarterly hospice care conference meetings and obtain the hospice plan of care for a resident receiving hospice services. In addition, the facility failed to ensure insulin injection sites were rotated for two residents, with multiple insulin administrations documented repeatedly in the same abdominal site. The facility further failed to complete the required neurological assessments after an unwitnessed fall for one resident, with several scheduled assessments missing from the neurological flowsheet.
Failure to Notify Physician and Follow Ordered Weight Monitoring
Penalty
Summary
The facility failed to ensure necessary nutritional monitoring and physician notification for two residents with significant weight loss. Resident 20, who had intact cognition with a BIMS score of 15, weighed 270 pounds on 3/4/26 and 256 pounds on 4/5/26. A care plan problem revised on 4/8/26 addressed nutritional risk and included monitoring, recording, and reporting to the physician as needed. An SBAR communication form dated 4/8/26 documented that Resident 20 had lost 5% of body weight within the past month, but the provider notification and feedback section remained pending, and the nurses’ progress notes did not show a follow-up call to inform the physician of the weight loss. Resident 28, who had a BIMS score of 12, had an SBAR communication form dated 2/11/26 documenting an 11.8% weight loss in six months, with the RD recommending weekly weights for four weeks. The Weights and Vitals Summary showed weights recorded on 2/3/26, 3/4/26, and 4/5/26, but did not show weekly weights for four weeks after the weight loss was identified. CNA 4 verified Resident 28 was not on the February 2026 weekly weight monitoring list, and RN 2 verified the RD recommendation and the absence of recorded weekly weights. The DON was informed of and acknowledged the findings.
GT Feeding Bag Not Labeled With Start Time
Penalty
Summary
The facility failed to ensure appropriate care and services for the use of a gastrostomy tube for Resident 5. Resident 5 was admitted and later readmitted to the facility, and the medical record showed a physician’s order for Peptamen 1.5 enteral feeding at 50 ml per hour, to start at 1200 hours until 1000 ml had infused. During observation on 4/20/26 at 0827 hours, Resident 5 was lying in bed with the GT feeding infusing at 50 ml/hr, and the Peptamen 1.5 feeding bag was labeled with the date of 4/19/26 and the rate, but the start time was not documented on the bag. During a concurrent interview and observation, LVN 9 stated that when a new enteral feeding bag is hung, it should be labeled with the resident’s name, the date and time the feeding was started, and the infusion rate, and that enteral feeding formulas should be discarded after 24 hours. When asked when the current feeding had been started, LVN 9 verified the label and stated she did not know when it was started. The DON later stated that enteral feeding formulas are good for 24 hours and should be discarded after 24 hours, and that licensed nurses were expected to label the feeding with the resident’s name, ordered rate, and start date and time so the discard time could be determined.
Peripheral IV Access Not Properly Labeled or Discontinued
Penalty
Summary
The facility failed to provide the necessary care and services to maintain peripheral IV accesses for two residents. For one resident, the peripheral IV access in the right hand was observed with a transparent dressing that was not labeled with the date, time, and licensed nurse's initials when it was inserted. The resident had been admitted and readmitted to the facility, had the capacity to understand and make decisions, and had no active physician orders for IV medication or IV maintenance at the time of record review. For another resident, a peripheral IV access was observed in the left foot after IV antibiotic therapy had been completed. The resident had been admitted and readmitted to the facility and had no capacity to understand and make decisions. The IV administration record showed piperacillin sodium-tazobactam sodium IV therapy started on 4/10/26 and the last dose was given on 4/14/26. The record also showed IV site checks were documented through 4/15/26, but the medical record did not show that the physician was notified about continuation of the peripheral IV access when it was no longer being used for IV fluids or medications. Facility staff confirmed the findings during observation, interview, and concurrent record review. An RN verified the unlabeled peripheral IV access for the first resident and stated it had last been used the prior week. The same RN verified the second resident's IV therapy had been completed and that the peripheral IV access had last been checked six days earlier, with no documentation showing physician notification for continuation when not in use. The DON stated the peripheral IV access should be labeled with the insertion date and staff initials and should be discontinued within 24 hours when not in use.
Food Not Palatable or Appealing
Penalty
Summary
The facility failed to ensure food was appetizing and palatable for two residents who received meals prepared in the facility kitchen. The facility policy titled Standardized Menus, revised 12/19/22, stated the facility shall provide nourishing, palatable meals to meet residents’ nutritional needs based on the Recommended Daily Allowances of the Food and Nutrition Board of the National Research Council. During the initial tour, one resident stated the food was terrible and another resident stated the food was not good. During a regular meal test tray observation with the RD and MDS Coordinator, the pork cutlet with orange glaze, whole green beans, orzo rice, and blueberry crumble dessert bar were tasted. The RD stated the orzo rice lacked flavor and had a mushy, too-soft texture, and the green beans were too soft. The MDS Coordinator stated the green beans were too soft and the orzo rice had no flavor and was soft, almost like puree. The Administrator and DON were later informed and acknowledged these findings.
Failure to Provide Ordered Beverage at Lunch
Penalty
Summary
The facility failed to accommodate the drink preferences for Resident 49 and did not provide the 120 ml of cranberry juice listed on the resident’s lunch meal ticket. Resident 49 was admitted to the facility and, according to the H&P examination dated 8/6/25, had the capacity to understand and make decisions; the diagnoses included ESRD and hemodialysis. The resident also had a physician’s order for a 1500 ml/day fluid restriction, with specific amounts assigned to nursing and dietary across the day. On 4/21/26 at 1307 hours, Resident 49 was observed eating lunch in a wheelchair in the room, and the meal tray had no beverage. During the concurrent interview, the resident stated she would like her juice. Review of the lunch meal ticket showed 120 ml of cranberry juice was listed in the beverage section. At 1310 hours, CNA 11 confirmed the resident was not served the cranberry juice that was listed on the meal ticket. On 4/23/26 at 1423 hours, the DON and Administrator were interviewed and acknowledged the findings.
Inaccurate Documentation of Blood Pressure Access Site for Two Dialysis Residents
Penalty
Summary
The facility failed to ensure the medical record for two residents receiving hemodialysis was complete and accurately documented. The facility's hemodialysis policy stated residents should not receive blood pressures or laboratory sticks on the arm where the dialysis access device is located. Both residents had physician orders and care plan interventions directing staff not to take blood pressures or draw blood from the left arm because of their dialysis access sites. For one resident, the record showed repeated blood pressure entries documented as taken on the left arm even though the resident had a left upper arm AV shunt and staff verified the readings were not actually obtained from that arm. The resident was observed with the AV shunt on the left arm and stated he went to dialysis three times a week. The LVN and DON confirmed the documentation was inaccurate and stated that taking blood pressure on the access site could increase the risk for infection, blood clot, or obstruction to the dialysis access. For the other resident, the medical record also showed multiple blood pressure readings documented on the left arm despite a physician order and care plan instruction not to use that arm. The resident was observed with a left arm AV shunt and stated staff had not taken blood pressures from the left upper arm. During interview and record review, RN staff verified the blood pressure documentation was inaccurate and stated the resident's blood pressure should not be taken from the left arm because of the AV shunt and physician order.
Inaccurate Daily Nursing Staffing Postings
Penalty
Summary
The facility failed to ensure that two of two posted daily nursing Direct Care Service Hours Per Patient Day (DHPPD) postings reviewed contained accurate information. The facility policy titled Nursing Staffing Posting information, revised 3/10/25, stated that nurse staffing information was to be posted daily in a readable format and include the facility name, current date, current resident census, and the total number and actual hours worked by RN, LPN/LVN, and CNA staff directly responsible for resident care per shift. The policy also stated the Nursing Staffing Sheet would be posted at the beginning of each shift. On 4/20/26, surveyors observed the DHPPD form dated 4/16/26 posted near the 2nd floor elevator entrance and in the front lobby. A separate facility form showing projected and actual NHPPD was dated 4/17/26. RN 3 and the DON both verified that the posted daily nursing PPD did not show the current PPD information. During a later interview, the DON stated the DSD was responsible for removing the old projection and replacing it with the new projection each day, and acknowledged that the daily nursing PPD posting was important because of frequent admissions and discharges. The Administrator and DON were informed of and acknowledged the findings.
Failure to Obtain Physician Discharge Order and Complete Post-Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident’s discharge was ordered and assessed by a physician in accordance with its transfer/discharge policy. The facility’s policy required the physician to document medical reasons for transfer or discharge in the medical record for any reason other than nonpayment or facility closure, and to attach a copy of the physician’s discharge order to the discharge notice. For community discharges, the policy also required preparation of a discharge summary and plan of care. The resident, who had been admitted on an earlier date and had a history and physical dated 6/8/25 indicating capacity to understand and make decisions, received a Notice of Proposed Transfer and Discharge dated 1/27/26. The notice cited that the resident’s health had improved sufficiently so that facility services were no longer required and that the resident had failed, after reasonable and appropriate notice, to pay, and it identified the name and address of the board and care facility to which the resident was to be discharged. Despite this, review of the resident’s Order Summary Report dated 2/27/26 showed no physician’s order for discharge. The Post Discharge Plan of Care and Summary report dated 1/7/26 contained incomplete documentation from nursing and social services. Further review of the last two physician progress notes dated 2/3/26 and 2/13/26 did not show documentation that the resident’s health status had improved or that the resident was deemed safe for discharge. During an interview and concurrent record review on 3/3/26, an RN confirmed that a physician’s order is required for discharge and that the Post Discharge Plan of Care and Summary must be completed by the IDT prior to discharge, and verified that the resident did not have a discharge order and that the post-discharge documentation was incomplete. The Administrator was informed of and acknowledged these findings.
Inaccurate and Conflicting Nursing Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that documentation in a resident's medical record was factual, accurate, and consistent with accepted professional standards, as required by its policy titled "Documentation in Medical Record" revised 12/19/22. For one resident, the physician progress note dated 1/31/26 documented that the resident was nonverbal, and the MDS assessment indicated severe cognitive impairment. However, multiple nursing progress notes and skilled nursing evaluations from 1/31/26 to 2/2/26 documented that the resident denied pain or discomfort, followed commands, denied weakness, tremors, numbness, or tingling, was alert and oriented x3, communicated verbally with clear speech, and had only mild cognitive impairment with some confusion. These entries conflicted with the physician documentation and MDS findings that the resident was nonverbal and severely cognitively impaired. Additionally, the nursing progress notes contained documentation of nursing care being provided to the resident after discharge. The record showed the resident was transferred to the hospital on 2/2/26 for a low hemoglobin level, yet a nursing progress note dated 2/4/26 documented that the resident was on GT feeding, had a wound vac in place and functioning as ordered, was receiving IV antibiotics, and had no signs of active infection. During an interview and concurrent record review on 2/12/26, the DON acknowledged confusion and inaccuracies in the nursing record, stating that the documentation made it appear the resident was nonverbal on one shift and then alert and talking on the next, and that the resident had left on 2/2/26 so the nurse could not have assessed the resident on 2/4/26. The DON stated it was unclear whether nurses were actually performing assessments or copying and pasting documentation and affirmed that she expected the documentation to be accurate.
Failure to Develop Accurate Baseline Wound and Nutritional Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission that accurately reflected a resident’s identified conditions and physician orders. Policy and procedure required a baseline care plan within 48 hours that included minimum health care information and interventions for special needs such as wound care and dietary orders. The resident was admitted with severe cognitive impairment and an initial skin assessment documented 10 pressure injuries and wounds, including pressure injuries to the sacrococcygeal area, hips, gluteal fold, heel, side of the right foot, a surgical incision with separated wound edges, a skin tear on the right arm, and open wounds on the right knee and left ear. Despite these findings, review of the baseline care plan initiated shortly after admission showed no care plan addressing pressure injuries or wounds. During interviews, the IP, an LVN, and the DON each confirmed that no wound care plan had been developed for any of the resident’s wounds, and all stated that each wound should have its own care plan with specific interventions and goals, and that the absence of such a plan could compromise or jeopardize the resident’s plan of care. The facility also failed to create an accurate baseline nutritional care plan consistent with the resident’s NPO status and enteral feeding orders. Physician orders documented that the resident was NPO and receiving enteral tube feedings, and a swallowing evaluation noted loss of liquids/solids from the mouth, residual food after meals, and coughing or choking during meals or when swallowing medications. A physician progress note further documented that the resident was nonverbal, NPO, and fed via GT. However, the nutritional care plan developed for the resident included interventions such as honoring food preferences, offering substitutes if less than 50% of the meal was eaten, and allowing ample time to eat and drink, which implied oral intake. In an interview, the DON confirmed that the nutritional care plan did not reflect the physician’s NPO and enteral feeding orders and acknowledged that the care plan was incorrect and could have led staff to believe the resident was able to take food or water by mouth, with a stated risk of aspiration into the lungs if oral intake occurred.
Inaccurate Documentation of Resident Temporary Absences
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for one resident regarding temporary absences from the facility. The resident had a history and physical dated 12/12/25 indicating they could make their needs known and make medical decisions, and a physician’s order dated 7/5/25 allowing them to go out on pass for therapeutic purposes. An MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. The resident’s Release for Temporary Absence form documented multiple days on which the resident left the facility, with specific departure times recorded. However, on numerous dates listed in November and December, the resident’s Release for Temporary Absence form either had illegible return times or no return times documented at all. For example, on several days the resident’s departure time was recorded, but the return time was missing or not legible. Despite this, a Social Services Progress Note dated 12/9/25 stated that the resident was able to go out on pass every day for more than six hours a day, which conflicted with the incomplete documentation on the temporary absence form. Interviews with staff and the resident confirmed the inconsistencies in the record. The resident stated they received a copy of their medical records and verified they were able to go out on pass every day for more than six hours. The receptionist confirmed that the resident signed out and back in at the reception desk, but acknowledged that some return times were not documented on the form. The Social Services Director stated the receptionist left at 1900 hours and verified that some dates lacked return times, explaining that when the resident returned after 1900 hours there was no staff at reception to sign them back in. The ADON also verified that some return times were missing, stated the resident usually returned around 1800 hours, and indicated the resident should have been signing back in at the nursing station when the receptionist was no longer present. These findings showed the medical record did not accurately reflect the resident’s temporary absences and returns.
Failure to Follow Midodrine Hold Parameters for Hypotensive Resident
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and its own medication administration policy for one resident. Facility policy revised 12/19/22 required that medications be administered by licensed nurses or other legally authorized staff as ordered by the physician, including obtaining and recording vital signs when applicable and holding medications when vital signs were outside prescribed parameters. Resident 2, who had a history of congestive heart failure and hypotension and lacked capacity to make medical decisions, had a physician’s order dated 8/20/25 for Midodrine HCl 10 mg via GT every eight hours for hypotension, with instructions to hold the medication if systolic blood pressure (SBP) was greater than 100 mmHg. The resident’s care plan for hypotension dated 9/4/25 directed staff to administer Midodrine for hypotension, monitor vital signs, and notify the MD of significant abnormalities. Review of the January 2026 MAR showed that staff administered Midodrine multiple times when the resident’s SBP exceeded the ordered hold parameter of 100 mmHg. Specifically, the medication was given when SBP readings were 106/61, 156/78, 102/60, 112/71, 139/70, 139/68, 124/76, 136/70, 127/64, 116/68, 106/66, 138/68, 126/72, and 108/66 mmHg on various dates and times in January. During an interview and concurrent record review on 1/16/26, an RN confirmed the Midodrine order, verified that the medication had been administered despite SBP readings above 100 mmHg, and stated that the medication should not have been given on those occasions and that this could affect the resident’s health. The administrator and nursing consultant were informed of and acknowledged these findings.
Unqualified Social Services Director Employed in Large Facility
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for a facility with more than 120 beds, affecting the provision of medically related social services for 196 residents. The facility’s job description for the Social Services Director (SSD) specified that any facility with more than 120 beds must employ a qualified social worker on a full-time basis and that the social services department must be directed by a qualified professional social worker with at least a bachelor’s degree in social work or another human services field, such as sociology, gerontology, special education, rehabilitation counseling, or psychology, plus one year of supervised social work experience in a health care setting. Review of the SSD’s personnel file showed that the SSD’s highest level of education was a high school diploma, with no documentation of a bachelor’s degree in social work or a related human services field, although the SSD had prior SSD experience in another nursing facility. In an interview, the SSD confirmed she had been working full-time in the role for two and a half years and verified that her highest educational attainment was a high school diploma. The Administrator and Nursing Consultant were informed of and acknowledged these findings.
Failure to Identify, Report, and Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to identify, report, and investigate two separate allegations of abuse made by a cognitively intact resident against another resident. On two occasions, the resident reported feeling threatened, scared, and unsafe after being verbally threatened and intimidated by another resident, who was known to have a diagnosis of schizophrenia and a history of verbal aggression. The first incident involved the alleged aggressor raising a clenched fist and threatening to kill the reporting resident over a dispute about a wheelchair. The second incident involved the alleged aggressor threatening to cut the reporting resident into pieces. Both incidents were reported by the resident to facility staff, including an LVN and the DON. Despite these reports, the facility's Administrator, who also served as the Abuse Coordinator, was unaware of the allegations and did not initiate the required reporting to the state agency or conduct an investigation as outlined in the facility's abuse policy. The policy required immediate investigation and reporting of all alleged violations to the Administrator and state agency, with thorough documentation and follow-up. Interviews confirmed that the LVN and DON were informed of the incidents, but the Administrator did not receive this information and therefore did not fulfill the mandated procedures for abuse allegations. Additionally, another resident corroborated the occurrence of verbal threats by the alleged aggressor, stating that such behavior was frequent. The medical records indicated that the alleged aggressor lacked capacity to understand and make decisions, while the reporting resident was cognitively intact and able to articulate her concerns. The failure to follow established protocols for abuse allegations resulted in the incidents not being properly addressed or investigated by facility leadership.
Failure to Safeguard Resident's Personal Property Due to Incomplete Documentation
Penalty
Summary
The facility failed to provide reasonable care for the protection of a resident's personal property from loss or theft. Upon admission, the resident's personal belongings form was not signed by the resident, despite the resident having the capacity to understand and make decisions. The form was also not accurately completed, as it did not include all of the resident's personal items, such as a wallet and an undisclosed amount of money. The facility's policy required that all personal items be inventoried at admission and documented in the medical record, but this was not done in this case. Interviews with facility staff confirmed that the resident's signature was missing from the belongings form and that the documentation was incomplete. The resident later reported that a jacket containing a wallet with money was sent to the laundry, and while the wallet was returned, the money was missing. The missing items were not listed on the resident's belongings form, and staff acknowledged the deficiencies in documentation and procedure.
Failure to Document Physician Assessment Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure that the discharge process was properly followed for one of three sampled residents. Specifically, the medical record for the resident did not contain documentation from the physician indicating that the resident's health had improved sufficiently to warrant discharge from the facility. There was also no evidence that the physician had assessed the resident for a safe discharge prior to the planned discharge date. The facility's policy and procedure on transfer or discharge requires that the physician document the medical reasons for transfer or discharge in the medical record, except in cases of nonpayment or facility closure. Additionally, a copy of the physician's order for discharge should be attached to the discharge notice. In this case, although there was a physician's order indicating a possible discharge to a program with home health for safety evaluation, the medical record lacked documentation that the resident was assessed and determined to be ready for discharge by the physician. The resident involved had the capacity to understand and make decisions, as indicated by a prior history and physical examination. However, the absence of physician documentation regarding the resident's readiness for discharge and the lack of an assessment for a safe discharge were confirmed during a telephone interview with the Administrator, who verified the findings. This failure had the potential to result in an unsafe discharge for the resident.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 1 was affected by this deficient practice. Resident 1 is still residing in the facility. On 8/25/2025, IDT team notify primary care physician about discharge planning for resident 1. On 8/25/2025, Administrator in-serviced IDT team about facility policy and procedure for discharge planning and process. Administrator emphasize the need to involve primary care physician during discharge process to make sure PCP can assess and document resident's care needs and if safe for discharge. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All discharged residents were potentially affected by this deficient practice. On 8/25/2025, Medical records audited all residents discharged in the last 30 days for physician documentation and found no other issue. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: Administrator or designee will oversee the discharge planning and process. IDT team will initiate discharge planning during initial care plan meeting and notify PCP of the initial plan. Any resident found by IDT that indicated their health significantly improved, PCP will be notified and assess if resident is safe for discharge and document in their progress notes and order for discharge. If PCP agreed and documented that resident is safe for discharge, IDT team will start discharge process and notify the resident or responsible party. Medical record will audit all discharge residents' medical records to make sure compliance x 3 months. Any non-compliance will be reported to the Administrator. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: Administrator will report any findings and present them to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 09/11/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/30/2025 Audit all discharge residents' medical records to make sure compliance x 3 months. Any non-compliance will be reported to the Administrator. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: Administrator will report any findings and present them to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 09/11/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/30/2025
Ice Machines Not Maintained in Sanitary Condition
Penalty
Summary
Surveyors found that the facility failed to maintain three ice machines in sanitary working condition, as required by federal regulations. During observations with the Maintenance Director, residues of various colors (brown, yellow, gray, black, and red) were found on critical internal components of the ice machines, including the evaporator, water curtain, ice chute, and ice storage bin deflector. Additionally, stained metal screws were observed in the ice storage bin. These findings were verified by the Maintenance Director during the inspection. Further review revealed that the facility did not follow manufacturer specifications for cleaning one of the ice machines. The manufacturer’s instructions required the use of a specific scale remover (Scotsman Clear 1), but the vendor responsible for cleaning the machines used a generic cleaner (Nucalgon nickel safe ice machine cleaner) instead, citing cost and practicality as reasons. The vendor admitted to not using the appropriate cleaner for each brand of ice machine. At the time of the survey, 145 residents were receiving oral diets and were potentially affected by the condition of the ice machines.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: 145 residents were affected by this deficient practice. On 7/15/25, all three ice machines were immediately taken out of service by the maintenance director and designee; certified vendor inspected, served, and thoroughly sanitized the ice machines following the manufacturer's specific cleaning and scale removal instructions. On 7/16/25, Dietary Supervisor and designee contacted certified vendor to initiate replacement of identified non-compliant ice machines, and vendor confirmed delivery and installation of new ice machines on 8/1/25. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have the potential to be affected by this deficient practice. On 8/1/2025, Administrator and Maintenance Director checked all ice-handling processes and related equipment. All ice machine equipment was cleaned and sanitized. The ice machine inside the kitchen was replaced on 8/1/2025. No other noncompliance was found. On 8/1/2025, Ice machine technician in-serviced maintenance department on how to clean and sanitize the ice machine, making sure deep cleaning was done including compartments not easily visible using approved chemical for cleaning ice machine. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: Administrator or designee will oversee this process and compliance. Maintenance will do monthly deep cleaning and sanitation of ice machine. The dietary supervisor and designee will do daily ice machine cleaning and inspection, with records kept. Vendor will perform quarterly service and cleaning to ensure cleanliness and compliance with equipment and sanitation protocols. Administrator or designee will check the ice machine weekly and randomly for 3 months to make sure cleaning and sanitation compliance is being followed. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance: Integrate QA Process: The Administrator or designee will be responsible for ensuring the monitoring process remains in place to confirm compliance. Any findings and noncompliance will be immediately corrected and presented to the monthly Safety Committee meetings and the Quality Assurance (QA&A) committee meetings. The Plan of Correction was presented at the QA&A meeting on 8/14/25. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for 3 months. 5. Corrective action completion date: 8/1/2025. --- 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Residents 35, 36, 49, 51, 85, 122, 146, and 153 were affected by this deficient practice. On 7/23/2025, Maintenance Director re-assessed all residents 35, 36, 49, 52, 85, 122, 146, and 153 for entrapment to make sure measurement of zone 7 reflected on the form being used. On 7/23/2025, Administrator provided 1:1 in-serviced to Maintenance Director for facility policy and procedure for measuring entrapment and using the form that reflects zone 7 to show if it passes or fails.
Incomplete Bed Entrapment Assessments for Residents Using Bed Rails
Penalty
Summary
Surveyors identified that the facility failed to ensure accurate and complete entrapment assessments for residents using bed rails and grab bars. Specifically, for several residents, the Bed System Measurement Device Test Results Worksheets did not document whether Zone 7—the space between the head or foot board and the mattress end—was measured or whether it passed or failed the entrapment assessment. This omission was observed across multiple sampled and nonsampled residents, despite the presence of physician orders for bed rails or grab bars for mobility, turning, or repositioning. The facility's policy required regular inspection and assessment of all bed frames, mattresses, and bed rails to identify possible entrapment areas, but the documentation was incomplete for the required zones. Observations included residents in bed with bilateral grab bars or side rails elevated, and in some cases, residents were not present but their beds were observed with the rails in use. Medical record reviews confirmed that these residents had orders for the use of bed rails or grab bars, and in some cases, care plans addressed the risk of entrapment. However, the maintenance records failed to show complete measurements for all required entrapment zones, particularly Zone 7. Interviews with the Maintenance Director confirmed discrepancies and acknowledged that Zone 7 was not consistently assessed or documented, and in some cases, units of measurement were missing for other zones as well. The deficiency was further substantiated by interviews with facility leadership, including the ADON and DON, who acknowledged the findings. The lack of complete and accurate entrapment assessments had the potential to negatively impact residents by increasing the risk of entrapment, serious injury, or death, as described in the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. The facility's failure to adhere to its own policies and federal requirements for bed safety assessments was evident in the incomplete documentation and inconsistent measurement practices.
Plan Of Correction
2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents were potentially affected by this deficient practice. On 7/23/2025, the Maintenance director audited all residents' beds for entrapment measurement of zone 7, and all 182 residents were found to have issues related to the form use not reflecting zone 7 if it fails or passes the entrapment measurement. The Maintenance team immediately re-measured all zone 7 in resident beds, and the entrapment measurement form was revised to reflect zone 7 measurement of fail or pass. All zone 7 entrapment measurements passed. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The Administrator or designee will oversee this process and compliance. Maintenance will measure zone 7 for entrapment and make sure it reflects on the measurement for the entrapment form. Any bed not in compliance with zone 7 entrapment will be removed. The Administrator will review entrapment records randomly for compliance for 4 weeks and monthly thereafter. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The Administrator will monitor the effectiveness of the process and report any findings, which will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
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What surveyors actually found near you
We read the 4,020 citations issued within 25 miles in the last 12 months — including the 8 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.
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Nursing homes near Santa Ana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Town & Country | 1.2 mi | ★★★★★ | 27 | 0 |
| The Hills Post Acute | 1.3 mi | ★★★★★ | 32 | 0 |
| Advanced Rehab Center Of Tustin | 1.3 mi | ★★★★★ | 49 | 0 |
| Orange Healthcare & Wellness Centre, Llc | 1.7 mi | ★★★★★ | 23 | 0 |
| Mainplace Post Acute | 1.8 mi | ★★★★★ | 29 | 0 |
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