Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garden Grove Post Acute during CMS and state inspections, most recent first.
Unsigned Physician Discharge Summaries: The facility failed to ensure physician discharge summaries were signed and dated for three residents who were transferred or discharged. Two residents were sent to the hospital, including one after increased confusion and agitation and one after a fall, and one resident was discharged home with 24/7 HHC at a family member’s request. The ADON verified the discharge summaries were not signed and dated by the physician.
A facility failed to ensure a staff member was onsite on the night shift who could provide respiratory services for residents with oxygen titration orders. The DON verified that no RN was assigned on the listed nights and that LVNs worked the shift instead; the DON also stated LVNs could provide basic respiratory tasks and oxygen in emergent situations, but could not adjust oxygen liter flow or concentration in non-emergent situations. The facility assessment and order review showed multiple residents had active oxygen therapy orders, including orders for titration.
Kitchen sanitation and equipment cleanliness failures: During a kitchen tour, the DSS observed heavily marred cutting boards, a wet blender and wet serving pans stored before air drying, a hood with greasy residue, worn and deformed utensils, multiple spoons, ladles, scoops, and tongs with dry crusted residue, a dirty microwave used to warm residents’ food, and an ice machine with black dirt residue. The DSS verified the findings, and the Administrator and DON were informed.
Improperly Closed Garbage Dumpsters: The facility failed to ensure three of four outside garbage dumpsters had fully closed lids. During observation, the dumpster lids were partially propped open by cardboard boxes and clear trash bags, preventing them from closing. The DSS verified the finding and stated the lids should be closed at all times to prevent rodents and flies. The Administrator and DON were informed and acknowledged the issue.
Incomplete and inaccurate resident medical records. The facility failed to keep several residents’ POLSTs complete, including missing physician identifiers and dates, and one resident’s chart contained conflicting advance directive information. For another resident with intact cognition, the MAR showed midodrine was given when the SBP was above the ordered hold parameter, progress notes did not document those administrations, and multiple telephone orders remained unsigned. One resident also had an elevated BP documented without corresponding interventions or follow-up assessments.
The facility failed to fully implement its infection control surveillance program by limiting review to residents with signs and symptoms of infection who were also prescribed antimicrobials. The IP stated that Surveillance Data Collection Forms were used to assess McGeer's Criteria and classify infections as HAI or CAI, but residents with clinical signs of infection without antimicrobials were not evaluated under McGeer's Criteria and were not included in the surveillance process.
Incomplete informed consent for psychotropic medications: The facility failed to fully inform a resident or responsible party before using hydroxyzine and temazepam. The resident was not able to make their own medical decisions, and the psychotherapeutic drug consent forms for both meds did not include the benefits, possible side effects, or significant risks. RN verified the missing information, and the DON and Administrator acknowledged the findings.
Chipped and Peeled Paint in Resident Room: A resident was observed lying in bed in a room where the wall behind the bed had several areas of chipped and peeled paint. The Administrator reviewed a photo of the wall and acknowledged the condition.
A resident was transferred to the ER for increased confusion and agitation, later diagnosed with metabolic encephalopathy and urinary retention, but the record did not show a completed change-in-condition assessment or form before the transfer. The ADON confirmed the document should have been completed, and the DON and Administrator acknowledged the missing documentation.
A resident with intact cognition and physician-ordered CCHO minced and moist diet with thin liquids, plus a 4-ounce no sugar added health shake with meals, did not receive the ordered shake at lunch. During observation, the meal tray contained food, soup, and milk, but no diet shake; CNA and DSS both confirmed the omission. The resident’s care plan identified risk for weight loss and dehydration related to dementia, chewing and swallowing problems, and altered skin condition.
Unlabeled and undated peripheral IV dressing: A resident receiving IV abx for a UTI was observed with a peripheral IV in the left hand infusing medication, and the transparent dressing was unlabeled and undated. The resident’s record showed an order for ceftriaxone and a care plan for IV catheter monitoring, while facility policy required the dressing label to include the date, time, and initials. An RN and an LVN both confirmed the dressing should have been labeled and dated.
Pharmacist DRR recommendations were not followed through for two residents. One resident with intact cognition had delayed changes to levothyroxine timing and eye drop administration spacing, and the physician did not document the rationale for continuing BP meds despite repeated low BP readings. Another resident with no decision-making capacity had a pharmacist recommendation to rotate Lantus injection sites, but the order summary did not reflect that change.
Improper Medication Storage and Labeling: Surveyors found an open vial of lidocaine HCl for a resident that was not dated after opening, and staff confirmed it should have been dated. They also found expired COVID-19 testing kits stored in the medication supply room, which staff verified were expired and should not have been there.
The facility failed to keep hospice SN and CHHA notes in the records for two residents receiving hospice services. One resident had CHF and the other had Alzheimer’s dementia, and both had hospice care plans, but the hospice binder and medical records lacked the required visit notes. Staff interviews also showed confusion about who served as the hospice coordinator, with one LPN naming the DON and an RN naming the ADON.
Respiratory equipment was not kept clean for three residents receiving ordered treatments. Two residents' oxygen concentrators had dust-like particles and stains on the units while they were receiving continuous O2 via NC, and a third resident's nebulizer machine was observed dirty with dust-like particles all over it. Staff verified the equipment was dirty and acknowledged it should have been clean.
Physician telephone orders were not signed within the required timeframe for two residents. One resident had multiple unsigned orders for post-op eye drops, wound care, meds, and treatment for oral thrush, while another resident had unsigned orders for PT/OT, BP meds with hold parameters, lab work, and peri-procedure medication holds. The ADON acknowledged the orders were not signed per facility policy, and the DON and Administrator were informed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to compliance with care planning and delivery requirements.
A resident with a history of falls and requiring significant assistance was found lying on a floor mattress, but staff did not recognize this as a fall and failed to assess the resident or notify the physician and family as required by facility policy. The DON confirmed that the incident was not documented or followed up according to post-fall procedures.
Two residents received gastrostomy tube (GT) care that did not match physician orders: one was given enteral feeding at a higher rate than prescribed, and another received water flushes at a lower rate than ordered. Nursing staff and medical record reviews confirmed these discrepancies.
A resident with limited upper extremity range of motion and a history of falls was observed twice with the call light out of reach while in bed, despite facility policy and the resident's care plan requiring the call light to be accessible. Staff confirmed the call light was not within reach and acknowledged the expectation for it to be accessible at all times.
A resident was given Ozempic for diabetes management without a diabetes diagnosis and without care plan monitoring, and was also administered oxycodone for pain at times when pain levels were below the prescribed threshold, including when no pain was present. Facility policy requires medications to be administered as prescribed, but this was not followed.
A LVN left an unlabeled medication in a clear cup unattended on a resident's bedside table, despite the resident being unable to self-administer the medication. Both the LVN and ADON confirmed this was not in line with facility policy for safe medication administration.
A resident did not receive prescribed doses of ketotifen, an antiallergic medication, on two consecutive days because the medication was not re-ordered in time. The MAR reflected missed administrations, and the DON confirmed the lapse during review.
The facility failed to meet food safety and sanitation standards, with improper labeling, dating, and storage of food items, unsanitary kitchen utensils and equipment, and poor hygiene practices by staff. These deficiencies posed a risk of food-borne illnesses to 81 residents.
The facility failed to implement effective infection control practices, including a lack of a comprehensive water management plan and inadequate PPE usage by staff. Specific residents with open wounds and PICC lines were not properly attended to, posing a risk for disease transmission.
The facility failed to document abdominal girth measurements for a resident with a perforated gastric ulcer and did not verify bowel movement status before administering a stool softener to another resident, leading to deficiencies in care.
A facility failed to follow a physician's order for a resident's elbow splint application, leading to a lack of documentation and skin assessment. The splint was not applied as ordered, and there was no record of the times it was applied or removed. Interviews with staff confirmed the absence of documentation and the need for a physician's order for skin assessment.
A resident at high risk for falls was found without required floor mats on both sides of the bed, as per their care plan and physician's order. Despite the resident's severe cognitive impairment and history of falls, staff confirmed the absence of mats, acknowledging the oversight. The DON verified the deficiency, highlighting a lapse in implementing necessary safety measures.
A facility failed to document baseline measurements for a resident's PICC line, potentially delaying the identification of complications. Additionally, an enteral feeding water bag was mislabeled with another resident's name. These deficiencies were confirmed by facility staff and acknowledged by leadership.
The facility failed to follow physician's orders for oxygen therapy for two residents, with one receiving an incorrect oxygen rate and lacking a care plan, and another having improperly maintained equipment. These issues were confirmed by staff and acknowledged by the DON.
A resident with ESRD receiving hemodialysis experienced deficiencies in care at the facility, including lack of post-dialysis assessment, inaccurate fluid restriction documentation, absence of an emergency dialysis kit, and incomplete care plan for transportation. Staff interviews revealed inadequate documentation practices, and the DON acknowledged the failure to follow facility procedures.
The facility failed to provide necessary pharmaceutical services for two residents, leading to discrepancies in medication administration. One resident received artificial tears with different active ingredients than prescribed, while another had inconsistencies between the Controlled Drug Record and MAR for oxycodone. These issues were confirmed by staff and acknowledged by the DON.
A facility failed to follow proper procedures for psychotropic medication management for a resident with dementia. Seroquel was prescribed without a documented diagnosis, informed consent, or least restrictive measures. The care plan was delayed, and side effects were not monitored. Ativan was prescribed without clinical indication. RN 1 confirmed these deficiencies, highlighting lapses in protocol adherence.
The facility failed to update its policy on outside food handling and did not educate staff and visitors on safe practices, posing a risk of foodborne illness. The P&P discouraged bringing potentially hazardous foods and stated they should not be stored or reheated, yet inconsistencies were found in practice. The DSD and DON provided conflicting information on food storage, and no education was provided on safe handling.
A resident was found with Glucosamine/Chondroitin at their bedside without a physician's order and was not qualified to self-administer medications. The facility's policy requires an IDT assessment for self-administration, which indicated the resident was not a candidate due to fluctuating decision-making capacity. The resident self-administered the medication, brought by their daughter, posing potential risks. The DON confirmed that unqualified residents should not have bedside medications.
A facility failed to accurately code the MDS for a resident with ESRD receiving hemodialysis, potentially affecting individualized care plans. The MDS Coordinator confirmed the error, acknowledging the resident's ongoing dialysis treatments. The DON, Administrator, and Nurse Consultant were informed of the findings.
A facility failed to update the care plan for a resident who frequently removed their nasal cannula, which was necessary for oxygen administration. Despite staff awareness and regular checks, the care plan did not address the resident's behavior, potentially affecting the care provided. The issue was acknowledged by the facility's administration.
The facility failed to properly store medications and remove expired items from medication carts. Diclofenac sodium topical gel was stored with oral medications, risking cross-contamination, and two expired skin staple removers were found. LVNs confirmed these issues, and the DON acknowledged the need for better checks by staff.
A resident's enteral feeding water bag was mislabeled with another resident's name, leading to potential risks due to incomplete and inaccurate medical information. The error was confirmed by an LVN and acknowledged by the DON, Nurse Consultant, and Administrator. RN 2 indicated that both night and morning shift nurses should check the labels to prevent such errors.
A resident received the influenza vaccine without informed consent from their responsible party, as required by the facility's policy. The resident was unable to make medical decisions, and the oversight was confirmed by the DSD, Administrator, and DON during a review.
A resident alleged being hit by a staff member, but the facility failed to thoroughly investigate by not interviewing the resident's roommate or other residents who might have been affected. The DON confirmed the investigation was concluded without these necessary interviews, contrary to the facility's policy.
The facility failed to administer Xeloda medication as per physician's orders for a resident and did not follow up timely with the physician when another resident had a hypertensive episode. These lapses in care were confirmed through medical record reviews and staff interviews.
Unsigned Physician Discharge Summaries
Penalty
Summary
The facility failed to ensure that physician discharge summaries were signed and dated for three residents who were transferred or discharged from the facility. Resident 6 was transferred to the acute care hospital for increased confusion and agitation, and Resident 41 was transferred to the acute care hospital after a fall incident; both residents were documented as unable to make their own medical decisions. Resident 5 was discharged to home with 24/7 home health care at the request of a family member, and the resident was documented as having the capacity to understand and make her own medical decisions. For each of these residents, the physician's discharge summary documented the reason for the transfer or discharge, but the documentation was missing the physician's signature and date. The facility's ADON verified that the transfer packet was supposed to include the physician summary discharge and confirmed that the discharge summaries for Residents 5, 6, and 41 were not signed and dated by the physician. The DON and Administrator were informed and acknowledged the findings.
No Onsite RN for Night Shift Oxygen Titration
Penalty
Summary
The facility failed to ensure a staff member was onsite during the night shift who could provide respiratory services to residents with oxygen titration orders. The report states that on 11/24/25, 11/25/25, 4/6/26, 4/12/26, 4/19/26, 6/8/26, 6/15/26, and 6/22/26, the facility did not have a nurse on site during the night shift who could adjust oxygen liter flow or oxygen concentration for residents whose orders required titration. Review of the facility assessment showed the resident population included conditions such as COPD, pneumonia, asthma, chronic lung disease, and respiratory failure, with an average of four residents receiving routine oxygen therapy and 14 receiving oxygen as needed. The order listing report dated 6/22/26 showed 15 of 87 residents had active oxygen orders, and 14 had orders to titrate oxygen as needed. The DON verified that on the listed dates the facility did not have an RN assigned to the night shift and that LVNs were assigned instead; the DON also stated LVNs could provide basic respiratory tasks and oxygen in emergent situations, but not adjustment or titration of oxygen liter flow or oxygen concentration in non-emergent situations.
Kitchen sanitation and equipment cleanliness failures
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen during an observation and concurrent interview with the DSS. The kitchen contained multiple cutting boards that were observed to be fuzzy, heavily marred, and marked with deep grooves and pits. The DSS verified that the cutting boards should have been replaced, and the facility’s policy required separate chopping boards for meats and vegetables and for boards to be thoroughly cleaned and sanitized after each use. The facility also failed to ensure equipment and utensils were properly air dried and stored. A heavy-duty blender used for puree preparation was observed wet with visible water inside while stored on a countertop shelf, and three stainless steel square serving pans were observed stacked while still wet with visible water. The DSS stated these items should have been air dried to prevent bacterial growth. In addition, the kitchen hood over the stove had yellowish, greasy residue, and the DSS acknowledged the finding while noting the hood was cleaned weekly and by an outside company every three months. Further observations showed kitchen utensils and equipment were not maintained in clean and sanitary condition. One basting brush used for barbecue meat had frayed bristles and was worn out, and two stainless steel whisks were deformed. Multiple utensils, including spoons, ladles, serving scoops with different colored handles, and tongs, were observed dirty with dry, crusted residue. The kitchen microwave used to warm residents’ food was dirty with dry food residue in the door and dry food splatters inside. The ice machine used for residents and staff had black dirt residue on the internal panel adjacent to the water curtain above and lateral to the ice bin. The DSS verified each of these findings during the kitchen tour, and the Administrator and DON were later informed and acknowledged the findings.
Improperly Closed Garbage Dumpsters
Penalty
Summary
The facility failed to ensure garbage was properly stored in three of four outside dumpsters. During observation and concurrent interview, the dumpsters were found with lids partially propped open by cardboard boxes and clear trash bags, which prevented the lids from fully closing. The facility's policy titled Miscellaneous Areas, Garbage and Trash dated 2023 required garbage and trash cans to be inspected daily to ensure no debris was on the ground or surrounding area and that lids were closed. The DSS verified the observation and stated the dumpster lids should be closed at all times to prevent rodents and flies. The Administrator and DON were later informed of and acknowledged the findings.
Incomplete and inaccurate resident medical records
Penalty
Summary
The facility failed to ensure medical records were complete and accurately maintained for six sampled residents. The deficiencies involved incomplete POLST forms, inaccurate medication administration documentation, unsigned telephone orders, conflicting advance directive documentation, and an inaccurate blood pressure entry. Facility policy required clinical records to be current, detailed, accurate, timely, and authenticated, and the POLST policy required the order to be recorded on physician orders after the physician signs and dates it and it is filed in the resident’s clinical record. Resident 3 had no capacity to understand and make decisions, and the POLST was signed by the physician but did not include the physician’s printed name or the date of the physician’s signature. Resident 11’s POLST was missing the physician’s printed name, phone number, license number, and date. Resident 16’s POLST was missing the physician’s phone number and license number. Resident 48’s POLST was missing the physician’s phone number. Resident 79’s record contained an Advance Directive Acknowledgement form showing an executed advance directive, but the POLST stated the resident did not have an advance directive, creating conflicting documentation in the chart. Resident 8 had intact cognition and an order for midodrine HCl 10 mg three times daily for hypotension, to be held if SBP was greater than 130 mmHg. The MAR showed the medication was administered on multiple occasions when the SBP was above that threshold, and the progress notes did not document those administrations. The chart also contained several unsigned telephone orders, including orders for a cardiology follow-up, bilateral knee x-ray, pacemaker monitoring, acetaminophen PRN, lidocaine patches, and discontinuation of a lidocaine patch order. Resident 48 also had a blood pressure reading documented as 228/74 mmHg, but the record did not show interventions or follow-up assessments for that elevated reading.
Infection surveillance program not applied to all residents with signs of infection
Penalty
Summary
The facility failed to implement its infection control surveillance program in accordance with its policy and procedure. The facility's Infection Control policy stated that the infection control program includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, and that the Infection Preventionist monitors and tracks residents' clinical status using the revised McGeer's Criteria. However, the facility conducted surveillance only when residents with signs and symptoms of infection were also prescribed antimicrobial medications, and did not include residents who had clinical signs and symptoms of infection but were not prescribed antimicrobial medications. During interview and document review, the Infection Preventionist stated that a Surveillance Data Collection Form was initiated when a resident exhibited signs and symptoms of infection and was prescribed antimicrobial medications, and that he reviewed those forms to determine whether McGeer's Criteria were met and whether the infection was hospital-associated or community-associated. Review of the monthly Infection Prevention and Control Surveillance Logs from August 2025 through May 2026 showed residents categorized as HAI, CAI, DNMC, and CSIWAM, but all residents identified as HAI or CAI were also prescribed antimicrobial medications. For residents with clinical signs of infection without antimicrobial medications, the Infection Preventionist stated the facility did not make a determination using McGeer's Criteria and was unable to determine how many such residents met the criteria for infection during that period.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to fully inform Resident 6 or the resident's responsible party and obtain completed informed consent before using psychotropic medications. Resident 6 was admitted and later readmitted to the facility, was able to make needs known, but was not capable of making their own medical decisions. The medical record showed physician orders for hydroxyzine HCl 50 mg as needed for itching, anxiety, aggression, and pruritic or severe anxiety, as well as temazepam 7.5 mg as needed for sleep aid/insomnia. Review of the Psychotherapeutic Drug Informed Consent forms showed that the consent for hydroxyzine 50 mg twice daily as needed for anxiety did not include the medication's benefits, possible side effects, or significant risks. The consent for temazepam 7.5 mg as needed for insomnia also lacked the benefits, possible side effects, and significant risks. The MAR showed hydroxyzine was administered multiple times in March and April 2026. During interview, RN 1 stated the purpose of the consent form was to inform the resident and responsible party of the medication's purpose, side effects, and benefits, and verified the findings. RN 1 stated the consent forms were not completed because the required information was missing. The DON and Administrator were later informed and acknowledged the findings.
Chipped and Peeled Paint in Resident Room
Penalty
Summary
The facility failed to maintain a homelike environment for Resident 67, who resided in Room A. During observation, Resident 67 was lying in bed while the wall behind the bed was observed to be in disrepair, with several areas of chipped and peeled paint. The deficiency was identified during surveyor observation, and the Administrator later reviewed a photo of the wall and acknowledged the condition of the room wall.
Missing Change-in-Condition Assessment Before Hospital Transfer
Penalty
Summary
The facility failed to ensure the necessary care and services were provided before transferring Resident 6 to the acute care hospital. Resident 6 was admitted to the facility and later readmitted, and the H&P dated 2/6/25 stated the resident could make needs known but was not capable of making medical decisions. On 4/15/26, a physician’s telephone order directed transfer to the ER due to increased confusion and agitation, and the discharge summary stated the transfer was necessary because of increased confusion and agitation. The resident was admitted to the acute care hospital at 1330 hours for metabolic encephalopathy and urinary retention. The medical record did not show assessment documentation or a completed change in condition form before the transfer to the acute care hospital. Progress notes reviewed did not include an assessment of the resident’s change in condition prior to hospitalization. The facility’s P&P stated the change in condition SBAR tool was optional but that the facility remained responsible for a thorough assessment of the resident’s change in condition, timely assessments, and contact with the primary care provider. During interview and record review, the ADON stated a change in condition document should be completed if a resident was transferred to the acute care hospital, but the documentation was not found in Resident 6’s record. The DON and Administrator were informed and acknowledged the findings.
Missed Ordered Health Shake With Meal
Penalty
Summary
The facility failed to provide a health shake with meals to Resident 8 as ordered by the physician. During a dining observation, Resident 8 was sitting in bed with a lunch tray that included rice, minced chicken, minced vegetables with gravy, soup, and an empty milk container. The meal ticket for lunch indicated that the resident was to receive four ounces of milk and four ounces of diet shake, but the diet shake was not present on the tray. When shown the meal ticket, Resident 8 stated no when the diet shake was pointed out. CNA 5 verified that Resident 8's lunch tray did not include the diet shake, and the DSS also confirmed the omission. Resident 8's medical record showed a BIMS score of 15 and physician's dietary orders for a CCHO minced and moist diet with thin liquids, along with an order for a four-ounce no sugar added health shake with meals. The nutrition risk care plan identified the resident as at risk for weight loss and dehydration related to dementia, chewing and swallowing problems, and altered skin condition, with interventions including providing diet as ordered and adhering to food preferences.
Unlabeled and undated peripheral IV dressing
Penalty
Summary
The facility failed to provide the necessary care and services to maintain intravenous access for one sampled resident, Resident 16, who was receiving IV antibiotic therapy for a UTI. During observation, Resident 16 was lying in bed with a peripheral IV line in the left hand infusing IV antibiotics. The IV site had minimal redness and swelling, and the transparent dressing was observed to be unlabeled and undated. The resident’s medical record showed a physician’s order for ceftriaxone sodium 2 gm IV daily for seven days, and the care plan identified the need for a peripheral IV catheter and frequent monitoring of the site for signs of complications. The facility’s policy for peripheral venous catheter insertion required the dressing label to include the date, time, and initials. During interview, an RN confirmed the dressing should have been labeled and dated, and an LVN stated the IV dressing should have been labeled with the date, time, and initials when inserted. The RN also stated the IV antibiotic infusion was stopped and a new IV line would be reinserted. The Administrator and DON were informed of the findings and acknowledged them.
Pharmacist Drug Regimen Review Recommendations Not Followed Through
Penalty
Summary
The facility failed to ensure that pharmacist recommendations from the Drug Regimen Review were followed through for two residents. The facility’s policy stated the Director of Nurses receives the pharmacy consultant’s recommendations, sends them to the attending physician, and the physician is to respond within 72 hours or the licensed nurse is to call the physician. The policy also required the attending physician to document the irregularity reviewed, the action taken, and the rationale if no changes were made. For one resident with intact cognition and a BIMS score of 15, the pharmacist recommended changing levothyroxine administration time from 0900 to 0630 to improve absorption, and recommended adding a five-minute wait between Latanoprost and cyclosporine eye drops. The levothyroxine time change was not carried out until five days later, and the eye drop spacing change was not ordered until 17 days after the recommendation. The same resident’s record also showed repeated low BP readings and a pharmacist recommendation to review metoprolol and midodrine, but the physician’s response only stated to continue current treatment and did not document the rationale for not changing the BP medications. For another resident with no capacity to make medical decisions, the pharmacist recommended adding rotation of injection sites to the Lantus Solostar order to improve therapeutic efficacy and reduce adverse drug reactions. Although the provider follow-through section indicated the recommendation was done, the resident’s order summary did not show any change to include rotating injection sites. Interviews with the ADON, LVN, DON, and Administrator confirmed the recommendations were not completed in a timely manner or were not reflected in the medical record as required.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to provide necessary pharmacy services to ensure proper storage, labeling, and disposal of medications in one medication room and one medication cart inspected. During inspection of Medication Cart D, surveyors found an open vial of lidocaine HCl 1% 200 mg per 20 ml for Resident 55 that was not dated after opening. LVN 4 and LVN 7 both verified that the vial had been opened and was undated, and both stated that opened vials should be dated. Resident 55’s record showed the resident was admitted to the facility, did not have the capacity to understand and make decisions, and had an order for lidocaine injection solution in the morning for diluent of ertapenem sodium until a specified date. Surveyors also inspected Medication Supply Room A and found a box containing 24 COVID-19 testing kits with an expiration date that had passed. The ADON and IP 1 verified the expired kits were in the medication supply room, and IP 1 stated the kits should not be stored there because they were expired. The facility’s medication storage policy stated medications and biologicals are to be stored safely, securely, and properly, and outdated, contaminated, or deteriorated medications are to be immediately removed from stock.
Missing Hospice Documentation and Unclear Hospice Coordinator
Penalty
Summary
The facility failed to provide the necessary care and services for two residents receiving hospice services by not ensuring that hospice skilled nurse visit notes and CHHA notes were available in the residents’ medical records. For one resident, the record showed admission to hospice for chronic systolic congestive heart failure on routine level of care, with a care plan reflecting hospice services, but the hospice binder and medical records did not contain the June 2026 skilled nurse hospice progress notes or CHHA notes. For the other resident, the record showed hospice services for Alzheimer’s dementia on routine level of care, with a care plan reflecting hospice involvement, but the hospice binder and medical records did not contain the May and June 2026 skilled nurse hospice progress notes or CHHA notes. The facility’s policies required communication between the facility and hospice provider to be documented and required designation of a facility interdisciplinary team member to coordinate with hospice representatives. During interviews, an LVN verified that the hospice documents should have been in the binder or medical record for communication and awareness of what to follow through for the residents. The LVN identified the DON as the hospice designee/coordinator, while an RN identified the ADON as the hospice coordinator, showing staff were not aware of a consistent hospice designee/coordinator.
Respiratory Equipment Not Kept Clean
Penalty
Summary
Safe and appropriate respiratory care was not provided for three residents who were receiving ordered respiratory treatments. The facility failed to ensure that two residents' oxygen concentrators were free of dust-like particles and stains, and failed to ensure one resident's nebulizer machine was maintained in a sanitary condition. The facility's policy stated resident equipment was to be cleaned and disinfected according to manufacturer guidelines and infection control policies, with cleaning after each use, daily, or as needed for resident-assigned equipment. Resident 3 was observed in bed receiving oxygen via nasal cannula from an oxygen concentrator at the bedside, and the concentrator had dust-like materials in front of the flow meter and on top of the unit. The resident had no capacity to understand and make decisions, had a physician's order for continuous oxygen at 2 liters per minute to keep oxygen saturation above 92% for shortness of breath and wheezing, and had a care plan identifying risk for altered breathing pattern and respiratory distress. Staff later verified the dust-like materials were present and stated the oxygen concentrator should be clean. Resident 7 was also observed in bed receiving continuous oxygen via nasal cannula from an oxygen concentrator that had cream-colored stains and dust-like particles on the front and top. The resident had no capacity to understand and make decisions and had a physician's order for continuous oxygen at 2 liters per minute to keep oxygen saturation above 92% for wheezing and shortness of breath. Resident 80 was observed with a nebulizer machine on the nightstand that was dirty and had dust-like particles all over it. The resident could make needs known but could not make medical decisions. Staff verified the nebulizer was dirty and acknowledged it should have been cleaned.
Physician Telephone Orders Not Signed Timely
Penalty
Summary
The facility failed to ensure the physician signed telephone orders in a timely manner for two sampled residents. Facility policy titled Physician Orders and Telephone Orders stated that telephone orders shall be signed within five days by the prescribing physician or extender as permitted by law. For Resident 6, who was admitted and later readmitted to the facility and whose H&P dated 2/6/25 showed the resident could make needs known but was not capable of making own medical decisions, multiple telephone orders lacked physician signatures, including orders dated 5/27/26 for ophthalmic medications after eye surgery, 6/9/26 for wound care to the right posterior skin tear, 6/16/26 for finasteride and mycophenolate mofetil, 6/17/26 for clobetasol ointment to both feet and the left palm, and 6/19/26 for nystatin suspension for oral thrush. For Resident 41, who was admitted to the facility and whose H&P dated 4/23/26 showed the resident could make needs known but was not capable of making own medical decisions, several telephone orders also lacked physician signatures. These included orders dated 5/21/26 for physical therapy, 5/28/26 for metoprolol tartrate with hold parameters, 6/16/26 for occupational therapy, and 6/17/26 for continued physical therapy, lab tests, holding medications before a procedure, and holding Eliquis before a procedure. During an interview and concurrent record review on 6/25/26, the ADON acknowledged the physician's orders were not signed as required by facility policy, and the DON and Administrator were informed and acknowledged the findings.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations.
Failure to Assess and Notify After Resident Found on Floor Mattress
Penalty
Summary
The facility failed to provide necessary care and services to prevent a fall incident for one of seven sampled residents. Specifically, when a resident with a history of falls and requiring substantial assistance for mobility and toileting was found lying on a floor mattress, the facility did not follow its own policies for post-fall assessment and notification. The facility's policies require that after any fall, a licensed nurse must immediately assess the resident, notify the physician and family, complete an incident report, and update the care plan. However, in this case, there was no documentation of an assessment, physician or family notification, or follow-up care and monitoring after the resident was found on the floor mattress. Interviews with staff confirmed that the incident was not recognized as a fall by the LVN who was informed, and therefore the required procedures were not initiated. The DON acknowledged that being found on the floor mattress should be considered a fall and that the fall policy should have been followed. The resident's medical record did not contain evidence of assessment or notification, and the DON was unaware of the incident until it was brought up during the survey. This failure to follow established protocols had the potential to negatively impact the resident's well-being.
Failure to Administer Prescribed GT Feeding and Water Flush Rates
Penalty
Summary
The facility failed to provide appropriate care and services related to gastrostomy tube (GT) management for two residents. For one resident, the prescribed enteral feeding rate of Glucerna 1.2 was 50 ml/hour, as ordered by the physician and documented in the care plan and nutritional assessment. However, observations revealed that the resident was receiving the feeding at a rate of 65 ml/hour, which was 15 ml/hour higher than the physician's order. This discrepancy was confirmed by both the nursing staff and a review of the medical records. For another resident, the physician's order specified a GT water flush of 35 ml/hour for 20 hours daily, totaling 700 ml/day. Despite this, the resident was observed receiving a water flush at a rate of 30 ml/hour, which was 5 ml/hour less than ordered. Nursing staff verified the order and acknowledged the lower rate being administered. Both residents were documented as lacking capacity to make medical decisions, and the deviations from prescribed care were confirmed through observation, staff interviews, and medical record review.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident by not ensuring the call light was within the resident's reach. Observations on two separate occasions showed the resident lying in bed with the call light clipped to the right corner of the mattress by the head of the bed, and the cord dangling off the bed, making it inaccessible to the resident. The resident's care plan specifically included an intervention to place the call light within reach due to a history of falls. The facility's policy also required staff to ensure call lights are easily accessible to residents when in bed or seated. Medical record review indicated the resident had clear speech, could sometimes make themselves understood, and had limitations in the range of motion in both upper extremities. The resident was able to use the call light when it was accessible. During an interview, a CNA confirmed the call light was not within reach and repositioned it accordingly. The DON stated that staff are expected to keep call lights within reach at all times.
Failure to Prevent Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications. One resident was administered Ozempic, a medication used to manage type 2 diabetes, despite having no diagnosis of diabetes mellitus (DM) as confirmed by the resident’s history and physical examination and a normal hemoglobin A1c level. The resident’s care plan did not address the use of Ozempic or include monitoring for its side effects. The Assistant Director of Nursing (ADON) confirmed that there was no care plan or monitoring in place for this medication and was unsure if the order had been clarified with the physician. Additionally, the same resident was given oxycodone 10 mg, prescribed for severe pain (pain level 7-10), on multiple occasions when the documented pain level was below the prescribed threshold, including several instances where the pain level was recorded as 0. The ADON verified that the medication should not have been administered when the resident had no pain and acknowledged that the medication should be given only as prescribed by the physician. The facility’s policy requires medications to be administered safely and as prescribed, but these requirements were not met in this case.
Medication Left Unattended at Bedside
Penalty
Summary
A licensed vocational nurse (LVN) left a white tablet inside an unlabeled clear cup unattended on a resident's bedside table. This action was observed during a medication pass, and the medication was not administered to the resident at that time. The resident was unable to self-administer the medication, and the LVN acknowledged that the medication should not have been left unattended and should have been taken back until the resident was ready to receive it. The facility's policy and procedure for medication administration states that medications must be administered in a safe manner, and if a resident is unavailable, the nurse should return later to administer the medication. Both the LVN and the Assistant Director of Nursing (ADON) confirmed that leaving the medication unattended on the bedside table was not in accordance with facility policy.
Failure to Administer Prescribed Medication as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to administer ketotifen, an antiallergic medication prescribed to help prevent asthma attacks, as ordered by a resident's physician. The facility's policy and procedure required medications to be administered as prescribed. Medical record review showed that the resident, who was cognitively intact and had a physician's order for ketotifen 1 mg capsules (two capsules twice daily for chronic urticaria), did not receive the medication on two consecutive days. The medication was not re-ordered in time, resulting in missed doses on the medication administration record (MAR) for those dates. The DON confirmed these findings during an interview and record review.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitation requirements in the kitchen, as evidenced by multiple observations of improper labeling, dating, and storage of food items. Opened food items in the freezer were not properly dated, and foods in the refrigerator were not labeled or dated correctly, with some items past their use-by date not being discarded. Additionally, juice boxes and thickeners were not labeled or dated, and food brought from outside for a resident was not properly labeled and stored. The kitchen utensils and equipment were not maintained in sanitary conditions, with observations of crusted residue on scoopers and spatulas, and debris in bins containing clean cooking utensils. Equipment was also found to be in poor condition, with a can opener having a chipped blade and portion servers with partially melted handles. Furthermore, there was significant ice buildup in bags of English muffins, and a sugar container was not properly covered. The kitchen staff did not adhere to proper hygiene practices, as one staff member with hairy forearms did not cover them during food preparation, and the same staff member failed to wash hands after using a dirty towel to clean surfaces before handling food. Additionally, expired sauces were found in a resident's room, which should have been labeled and stored in the refrigerator. These deficiencies had the potential to expose the medically vulnerable population of 81 residents to food-borne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement effective infection control practices, as evidenced by several deficiencies. The water management plan was not available, and the facility did not have a comprehensive program to address and monitor the growth of Legionella and other waterborne pathogens. The Maintenance Director was unable to provide documentation of a facility risk assessment or a completed water management plan, which should have included testing protocols and control measures. Additionally, the Administrator did not attend the quarterly infection control committee meetings, which are crucial for overseeing and implementing the infection control program. The facility also failed to ensure proper hand hygiene and personal protective equipment (PPE) usage among staff. The Laundry Attendant did not perform hand hygiene after handling soiled linens and before touching clean linens, and there were dirty items stored with clean linens. Staff members did not don appropriate PPE when providing care to residents with specific needs, such as checking blood sugar levels or assisting residents with PICC lines and surgical wounds. These lapses in infection control practices posed a risk for the transmission of disease-causing microorganisms to the residents. Specific residents were affected by these deficiencies. Resident 645, who had an open wound, was not properly attended to with the required PPE by the staff. Resident 745, with a PICC line and abdominal wounds, was not placed on Enhanced Barrier Precautions (EBP) as required, and the signage did not reflect the need for such precautions. Similarly, Resident 696, who was on EBP due to a pressure injury, was fed by a CNA who did not use the necessary gown and gloves. These failures highlight significant gaps in the facility's infection prevention and control program, directly impacting resident safety and care.
Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their care. For Resident 745, who was admitted with a diagnosis of a perforated gastric ulcer, there was a physician's order to measure the resident's abdominal girth every two days. However, the measurements for 3/3 and 3/5 were not documented, and the licensed nurse was unable to provide the measurements or confirm if they were compared to the baseline. This lack of documentation and comparison could potentially delay necessary medical intervention. For Resident 31, the facility failed to adhere to the physician's order regarding the administration of a stool softener. The order specified that the medication should be held if the resident had loose stools. During a medication administration observation, the LVN administered the stool softener without checking the resident's last bowel movement or asking if the resident had loose stools. The LVN acknowledged the oversight, and the DON confirmed that the nurse should have verified the resident's bowel movement status before administering the medication.
Failure to Apply Splint and Document Skin Assessment
Penalty
Summary
The facility failed to follow a physician's order for a resident, identified as Resident 80, regarding the application of an extension splint to the left elbow. The order specified that the splint should be applied for four to six hours a day on specific days of the week. However, during an observation, it was noted that the splint was not applied, and it was found in a plastic bag on the resident's cabinet. Additionally, there was no physician's order or care plan intervention to include a skin assessment when the splint was applied, which is crucial to prevent skin issues. Interviews with the Restorative Nursing Assistant (RNA) and a Registered Nurse (RN) revealed that although the splint was applied, there was no documentation of the exact times it was applied and removed, nor was there any documentation of a skin assessment. The RNA confirmed that she checked the skin after removing the splint but did not document this assessment. The RN acknowledged the lack of documentation and stated that a physician's order for skin assessment should have been obtained. The Director of Nursing (DON) was informed and verified these findings.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to provide the necessary care and services to prevent accidents for a resident identified as being at high risk for falls. The resident, who had severe cognitive impairment and required extensive assistance for activities of daily living, was observed without the required floor mats on both sides of the bed, as per the physician's order and care plan. The absence of these mats was noted during observations on two separate occasions, despite the resident's care plan and physician's order explicitly stating the need for bilateral floor mats to prevent or minimize injuries from falls. Interviews with facility staff, including a CNA, LVN, and RN, confirmed the resident's high fall risk and the requirement for floor mats. However, all staff acknowledged that the mats were not in place, despite the resident's history of falls and a previous incident of a witnessed fall. The Director of Nursing was informed of these findings and verified the deficiency, confirming that the necessary safety measures were not implemented as required by the resident's care plan and physician's order.
Deficiencies in IV and Enteral Feeding Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a PICC line, as baseline measurements of the PICC line external catheter length and arm circumference were not confirmed and documented in the medical record prior to administering IV antibiotics. Additionally, during a dressing change, the facility did not measure and document the PICC line external catheter length as required by the facility's policy and the resident's care plan. This oversight had the potential to delay the identification of catheter-related complications for the resident, who was admitted with a diagnosis of a perforated gastric ulcer and fluctuating capacity to understand and make decisions. The facility also failed to ensure that an enteral feeding water bag was accurately labeled with the correct resident's name. During an observation, it was found that a resident's enteral feeding water bag was incorrectly labeled with another resident's name. This error was verified by a licensed vocational nurse and confirmed by a registered nurse, who stated that enteral feeding bags should be checked by both night and morning shift nurses to prevent such errors. Interviews with the Director of Nursing, Administrator, and Nurse Consultant confirmed the findings of these deficiencies. The facility's policies and procedures were not followed, leading to potential risks in the administration of IV therapy and enteral feeding care. These failures were acknowledged by the facility's leadership during the survey process.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen therapy for two residents, leading to potential negative impacts on their medical conditions. For one resident, the oxygen was administered at a rate of 5 LPM instead of the prescribed 2 LPM, and there was no care plan developed for the use of oxygen. This discrepancy was confirmed by both a Registered Nurse Assistant (RNA) and a Licensed Vocational Nurse (LVN), who were unable to explain the increase in the oxygen rate. Additionally, the resident's care plans lacked documentation for oxygen use, which was verified by a Registered Nurse (RN). For another resident, the facility failed to maintain proper hygiene and equipment management for oxygen therapy. The resident's nasal cannula was observed touching the floor, and the nebulizer tubing was undated and improperly stored in a drawer. These observations were confirmed by an LVN, who acknowledged the issues and stated intentions to rectify them. The facility's Director of Nursing (DON) was informed and verified these findings, indicating a lapse in following the facility's policy for oxygen administration and equipment maintenance.
Deficiencies in Dialysis Care for a Resident
Penalty
Summary
The facility failed to provide necessary dialysis care and services for a resident, identified as Resident 34, who required such services. The deficiencies included a lack of assessment upon the resident's return from dialysis treatment, inaccurate documentation of fluid restriction monitoring, absence of an emergency dialysis kit at the resident's bedside, and an incomplete care plan that did not include transportation information for dialysis as per the facility's policies and procedures. Resident 34, who had end-stage renal disease (ESRD) and received hemodialysis, was not assessed for vital signs, weights, or hemodialysis site condition upon returning from dialysis sessions. The facility's records showed significant discrepancies in pre and post-dialysis weights, which were not clarified or communicated to the physician. Additionally, the resident's care plan lacked details about transportation arrangements to the dialysis center, and the emergency supplies required by the facility's policy were not available at the bedside. Interviews with staff, including an LVN and the DON, revealed that the facility's documentation practices were inadequate. The MAR did not accurately reflect the resident's fluid intake, and there was no documentation of the resident's departure and return times for dialysis. The DON acknowledged that the facility's procedures for dialysis communication and documentation were not followed, which contributed to the deficiencies in care for Resident 34.
Pharmaceutical Services Deficiency in Medication Administration
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for two residents, leading to discrepancies in medication administration. For one resident, the active ingredients in the artificial tears medication provided did not match the physician's order. The resident was prescribed artificial tears ophthalmic solution 1% with carboxymethylcellulose sodium, but the medication available contained glycerin, hypromellose, and polyethylene glycol 400. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN) during a medication administration observation, and the Director of Nursing (DON) acknowledged the issue, stating that the exact medication should have been ordered from the pharmacy. In another instance, the facility failed to ensure that the Controlled Drug Record matched the Medication Administration Record (MAR) for a resident's oxycodone hydrochloride, a narcotic pain medication. The Antibiotic or Controlled Drug Record indicated that the resident received the medication at a specific time, but this administration was not documented in the MAR. This inconsistency was verified by an LVN, who was unable to explain the discrepancy as the resident had been in a different station previously. The DON confirmed that the nurse should have signed both the controlled drug record and the MAR immediately after administering the medication. These failures in pharmaceutical services had the potential to negatively affect the residents' well-being and posed a risk of diversion of controlled medication. The discrepancies in medication administration and documentation were acknowledged by the facility's administration, including the DON and the Administrator.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper procedures were followed in the administration of psychotropic medications for Resident 56, who had a diagnosis of dementia. The resident was prescribed Seroquel, an antipsychotic medication, without a documented diagnosis prior to its initiation. Additionally, the facility did not obtain informed consent or implement least restrictive measures before starting the medication. The care plan for the use and monitoring of Seroquel was not created until several days after the medication was prescribed, and there was no monitoring for side effects such as postural hypotension. Furthermore, Resident 56 was prescribed Ativan, an antianxiety medication, on an as-needed basis for agitation, but there was no clinical indication or documented behaviors of agitation to justify its use. The facility's policies and procedures required informed consent and a specific diagnosis for the use of psychotropic medications, which were not adhered to in this case. The lack of documentation and failure to follow established protocols placed the resident at risk for receiving unnecessary medications and potential adverse reactions. During an interview, RN 1 confirmed the deficiencies, acknowledging that informed consent was not obtained, and least restrictive measures were not implemented before administering Seroquel. Additionally, RN 1 verified that there was no clinical indication for the use of Seroquel or Ativan, and the care plan for Seroquel was delayed. The facility's failure to monitor for side effects and obtain informed consent for Ativan further highlighted the lapses in following proper procedures for psychotropic medication management.
Failure to Update Policy and Educate on Safe Food Handling
Penalty
Summary
The facility failed to update its policy and procedures (P&P) regarding the handling of outside food brought in by visitors to meet state regulations. The existing P&P, last revised in September 2017, discouraged visitors from bringing potentially hazardous foods such as meats, fish, eggs, custards, and milk products. It stated that such foods should be consumed immediately and not shared with other residents, and that food items brought into the facility could not be reheated or stored. However, interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed inconsistencies in the implementation of this policy. The DSD stated that visitors were encouraged to bring food, which must be consumed immediately or taken home if not consumed, and confirmed that the facility did not store or reheat outside food. In contrast, the DON mentioned that the facility labeled and stored food in the refrigerator for up to 72 hours, which contradicted the written P&P. Additionally, the facility failed to provide education to staff and visitors on safe food handling practices to prevent foodborne illnesses. The DSD confirmed that no education was provided to staff or visitors regarding safe food handling, despite the potential risk of foodborne illness from improperly handled outside food. This lack of education and the discrepancies between the stated policy and actual practices posed a risk to residents consuming food from outside sources. The findings were acknowledged by the DON, Administrator, Nurse Consultant, and Registered Dietitian (RD).
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the safe self-administration of medication for one resident, identified as Resident 745, who was found with a bottle of Glucosamine/Chondroitin at their bedside. This resident did not have a physician's order to keep the medication at the bedside and was not qualified to self-administer medications according to the facility's assessment. The facility's policy requires an interdisciplinary team (IDT) assessment to determine if a resident can safely self-administer medications, and Resident 745's assessment indicated they were not a candidate for self-administration due to fluctuating capacity to understand and make decisions. During an observation, it was noted that Resident 745 had self-administered the medication, which was brought to the facility by their daughter. The RN confirmed that the resident was not a candidate for self-administration and highlighted the potential risks of drug interactions or overconsumption. The Director of Nursing (DON) stated that residents not qualified to self-administer should not have medications at their bedside. The findings were acknowledged by the DON, Administrator, and Nurse Consultant.
Inaccurate MDS Coding for Dialysis Treatment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident, which could impact the development of individualized care plans. Specifically, the MDS for a resident with End-Stage Renal Disease (ESRD) receiving hemodialysis was not coded to reflect the dialysis treatments. This oversight was identified during a medical record review initiated on March 5, 2025, and confirmed through an interview with the MDS Coordinator on March 6, 2025. The MDS Coordinator acknowledged that the resident had been receiving dialysis for over a year, and the MDS assessment was incorrectly coded. The Director of Nursing (DON), Administrator, and Nurse Consultant were informed of these findings on March 10, 2025.
Failure to Update Care Plan for Oxygen Management
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident 49, regarding the removal of oxygen. During an initial tour, Resident 49 was observed with a nasal cannula on their face, but the nasal prong was not in their nose. The nasal cannula was distributing oxygen at 2 liters per minute (LPM) and was connected to an oxygen concentrator. A medical record review showed that Resident 49 had a physician's order to administer oxygen at 2 LPM continuously to maintain oxygen saturation levels at 92% every shift. However, the care plan did not address the resident's behavior of pulling out the nasal cannula, which was verified by LVN 3 during an observation and interview. Further interviews revealed that the licensed nurses were aware of the resident's behavior and checked the nasal cannula every two hours. RN 2 confirmed the findings and stated that visual checks should be conducted every two hours, and adjustments should be made to prevent the nasal cannula from being dislodged. Despite these practices, the care plan was not updated to reflect the resident's behavior, which could potentially impact the necessary care and services provided to Resident 49. The Administrator and Director of Nursing (DON) were informed and acknowledged the findings.
Improper Storage and Expired Items Found in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and separation of medications, as observed during an inspection of Medication Cart B. The inspection revealed that diclofenac sodium topical gel, an external medication, was stored alongside oral medications such as calcium carbonate tablets, ferrous sulfate tablets, and acidophilus lactobacilli probiotic capsules. LVN 5 confirmed the improper storage and acknowledged that these medications should not be stored together due to the risk of cross-contamination. The Director of Nursing (DON) admitted that the licensed nurse should have checked the medication cart at the beginning of each shift to ensure proper separation of external and internal medications. Additionally, during an inspection of Medication Cart D, two expired skin staple removers were found. LVN 6 verified the expiration of these items and recognized the need to check expiration dates more diligently in the future. The DON acknowledged these findings and stated that the treatment nurse should have checked the treatment cart for expired items before starting treatments. The Administrator and DON were informed of these deficiencies and acknowledged the findings.
Mislabeling of Enteral Feeding Water Bag
Penalty
Summary
The facility failed to ensure that the enteral feeding water bag for one resident was accurately labeled, leading to a potential risk of unmet care needs due to incomplete and inaccurate medical information. During an observation, it was noted that the enteral feeding water bag for Resident 30 was incorrectly labeled with the name of another resident, Resident 46. This error was confirmed by LVN 8 during a concurrent observation and interview. Further interviews with RN 2 revealed that the enteral feeding bags should be checked by licensed nurses from both the night and morning shifts to prevent such errors. The Director of Nursing, Nurse Consultant, and Administrator also verified the finding.
Failure to Obtain Informed Consent for Influenza Vaccine
Penalty
Summary
The facility failed to obtain informed consent for the administration of the influenza vaccine to a resident, identified as Resident 38, during the 2024-2025 influenza season. Resident 38 was administered the influenza vaccine on September 20, 2024, without obtaining written consent from the resident's responsible party, as required by the facility's policy and procedure. The policy, revised in January 2024, mandates that written, informed consent be obtained from the resident or their decision maker prior to vaccine administration. A review of Resident 38's medical records revealed that the resident was unable to make medical decisions, necessitating consent from a responsible party. However, no such consent was documented. The Director of Staff Development (DSD) confirmed the oversight during an interview and acknowledged the failure to secure informed consent before administering the vaccine. The Administrator and Director of Nursing (DON) also acknowledged these findings, confirming the deficiency in the facility's adherence to its vaccination policy.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who claimed to have been hit in the head by a staff member. The facility's policy and procedure for abuse reporting and prevention required that all reported incidents of abuse be thoroughly investigated by the Abuse Coordinator or designee, including interviews with involved residents and other parties with knowledge of the alleged incident. However, the facility did not document interviews with Resident 1's roommate or other residents who might have been subjected to abuse by the alleged perpetrator. The Director of Nursing (DON) confirmed that the investigation process should include interviews with the alleged victim, involved staff, family, and anyone present at the time of the incident, including the roommate if the incident occurred in the resident's room. Despite this, the facility's investigation file lacked documentation of interviews with other alert residents who received care from the alleged perpetrator. The DON verified that the allegation of abuse was concluded without these interviews being conducted.
Failure to Administer Medication and Follow Up on Change of Condition
Penalty
Summary
The facility failed to ensure the Xeloda (capecitabine) medication was administered as per the physician's orders for Resident 5. Resident 5 was supposed to receive the medication in a specific cycle of two weeks on and one week off. However, the medical records showed inconsistencies in the administration of the medication, with missed doses in October 2023. Despite follow-up appointments with the oncologist, there was no documented evidence of the physician's orders being followed, and the medication was not administered as required. Interviews with the nursing staff and the Director of Nursing (DON) confirmed these findings and revealed a lack of proper follow-up and documentation regarding the medication administration. The facility also failed to follow up with the physician timely when Resident 4 had a change of condition involving an episode of hypertension with a blood pressure reading of 180/100 mmHg. Despite the high blood pressure readings and the resident's unresponsiveness, there was no documented evidence of timely notification to the physician or the Medical Director. The resident's condition was not adequately addressed, and the necessary follow-up actions were not taken. Interviews with the nursing staff and the DON confirmed that the physician was not contacted promptly, and there was no follow-up with the Medical Director as required by the facility's policy. These failures had the potential to negatively affect the residents' health conditions and well-being. The facility's policies and procedures for significant changes in condition and medication administration were not followed, leading to lapses in care for Residents 4 and 5. The lack of proper documentation, follow-up, and adherence to physician's orders contributed to these deficiencies, as confirmed by the medical record reviews and staff interviews.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Garden Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rowntree Gardens | 1 mi | ★★★★★ | 20 | 0 |
| Extended Care Hospital Of Westminster | 1.4 mi | ★★★★★ | 23 | 0 |
| Mission Palms Healthcare Center | 1.9 mi | ★★★★★ | 23 | 0 |
| Coventry Court Health Center | 2.7 mi | ★★★★★ | 1 | 0 |
| The Grove Post Acute | 2.9 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.