Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Hill Post Acute during CMS and state inspections, most recent first.
Staff searched a cognitively intact resident's personal belongings without her permission while attempting to locate her communication device. The resident, who had aphasia and right-sided weakness from a stroke, became visibly anxious and distressed after her roommate informed her that a male CNA and the SSD had gone through her items. Both staff later acknowledged they should have obtained the resident's consent before searching her belongings, contrary to facility expectations and resident rights policy.
A resident with aphasia and right-sided weakness from a stroke, but cognitively intact per BIMS, was involved in a motor vehicle accident while Out On Pass as a passenger in a car driven by her significant other, who had a seizure history. After the facility learned from the ED that the resident had been in an accident and returned, the IDT documented the event and recommended a care conference but did not develop or implement a care plan addressing the resident’s safety during future OOPs. The resident reported feeling scared and stated the driver should not drive her anymore, and nursing and leadership staff acknowledged they believed the significant other should no longer drive the resident; however, no corresponding OOP safety interventions were added to the care plan so that all staff would be aware.
Two residents with severe cognitive impairment and known fall histories experienced repeated falls because staff did not consistently implement or update individualized fall-prevention measures after each incident. One resident with dementia and Parkinson’s disease fell multiple times in her room, hallway, and dining area, with some falls lacking any new interventions and with fall-risk identifiers (such as a yellow wristband and floor mat placement) not consistently in use. Another resident with encephalopathy, dementia, and prior brain injury also had numerous falls, many occurring at night near his bed, some resulting in injury, and several without new fall-prevention steps documented. Staff interviews revealed poor awareness of the true number of falls, uncertainty about residents’ diagnoses, and inconsistent use of the facility’s fall-risk identification system, despite policies requiring observation for causes of falls and initiation of individualized interventions.
Surveyors found that the facility did not consistently develop and update individualized fall-prevention care plans for two cognitively impaired residents with extensive fall histories. Over multiple months, each resident experienced numerous falls in and around their rooms and common areas, yet care plans often lacked new or resident-specific interventions after events, and some falls prompted no new measures at all. Staff interviews revealed that the DON and direct-care staff were unaware of the total number of falls, some staff did not know the residents’ diagnoses or specific care plan details, and CNAs relied on verbal reports rather than reviewing care plans. Observations showed inconsistent use of the facility’s fall-risk identification system, including missing colored wristbands, and fall equipment not always in active use, despite internal documents stating that individualized interventions should be initiated after a fall.
Multiple cognitively intact residents and a family member reported that call lights for medications, toileting, and personal care were often unanswered for 40–90 minutes, despite repeated Resident Council complaints over several months. One resident with quadriplegia described frequent hour‑long waits and a 90‑minute delay for medication, while another resident left AMA after experiencing prolonged waits and hearing staff socializing near the nurses’ station instead of responding. A family member observed CNAs sitting at the nurses’ station while call lights alarmed and was told assigned staff were on break or busy. Surveyors observed staff walking past active call lights, turning off call lights without providing care, and addressing a private caregiver instead of the resident, with staff later acknowledging they should have responded differently. Several residents reported that staff routinely turned off call lights and returned much later, and facility leadership acknowledged that call light response remained an ongoing problem.
A resident with diabetes, hypertension, and heart failure did not receive multiple physician-ordered medications within 24 hours of admission, including diabetes, BP, cholesterol, anticoagulant, antidepressant, and ophthalmic medications, because they were documented by nursing staff as not available and pending pharmacy delivery. Over a five-week stay, the resident also received a prescribed weekly dulaglutide injection only twice despite five documented opportunities, with nursing notes repeatedly citing waiting for pharmacy or providing no explanation for missed doses. The DON reported that medications were expected to be available within eight hours of admission and that nurses should have escalated unavailable medications, but acknowledged that although unavailability was documented, the issue was not resolved and medications were not administered as ordered, contrary to facility policies on admission medication ordering and medication administration.
A resident did not receive a prescribed vitamin supplement because it was not in stock, and controlled medication records for several residents did not reconcile because doses signed out of the CDR were not documented on the MAR. In addition, PRN opioid pain medications were given to two residents when their documented pain levels did not meet the ordered criteria, including multiple doses given when one resident reported no pain. The DON and CP confirmed the documentation and administration issues.
A resident's care plan was found to be incomplete, lacking coverage of all needs and missing measurable timetables and specific actions. Surveyors observed that the care plan did not fully address the resident's requirements due to insufficient assessment and planning.
Dignity and Feeding Assistance Concern: A resident with paraplegia and blindness was observed during lunch while a CNA stood over the resident and fed the meal from a position that was not at the resident’s level. The CNA later acknowledged he should have sat down for the resident’s dignity and safety, and another CNA and the DON stated staff were expected to sit close to residents who need feeding assistance and explain the meal to residents who cannot see.
Failure to develop baseline care plans for a resident with a urinary catheter, a resident with pain needs, and a resident requiring oxygen. The record showed no baseline care plan for catheter care, pain management, or oxygen use, while staff interviews confirmed the missing plans. One resident had a urinary catheter and incomplete catheter-care documentation, another reported unmanaged pain and missed pain meds over the weekend, and a third used oxygen nearly 24 hours a day for respiratory failure with hypoxia.
A nurse administered two medications through a resident’s G-tube without flushing before the first medication or between the medications, despite an active order for water flushes before and after G-tube med administration. The nurse later confirmed the omission, and the DON confirmed the resident had an order for a 50 mL flush before and after med administration. The facility policy also required flushing before and after as ordered and in between each medication as ordered.
Failure to Provide Routine Nail Care: A resident with stroke history, altered mental status, moderate cognitive impairment, and left arm weakness was observed with long fingernails that had not been trimmed. The resident said he had asked staff for help, but was told a special person needed to cut them. A CNA and an LPN both stated the nails were long and sharp and should have been trimmed for hygiene and infection control, and the DON confirmed staff were expected to provide nail care.
Failure to Offer Individualized Activities: A resident with hemiplegia/hemiparesis, intact cognition, and a need for staff assistance with transfers was repeatedly observed staying in bed and reported being bored because staff did not get him up or offer him to attend activities. CNAs stated he needed a mechanical lift and did not have his own wheelchair, and an LN and the DON acknowledged staff should have offered leisure activities to support his emotional well-being.
Unlabeled Tube Feeding Formula: A resident with tongue cancer and a gastrostomy tube had tube feeding formula in the pump that was not labeled or dated. The MDSN stated the LNs should have labeled the tube feeding and water flush, and the DON stated the expectation was to include the resident’s name, flow rate, time, and date to ensure the correct feeding and hydration were being provided.
A resident with a midline catheter and intact cognition reported that the line had not been flushed for days and the dressing had not been changed since the last time it was done. Record review showed orders for routine flushing, every-shift site monitoring, and weekly dressing changes, but the MAR had multiple blank or missed entries for flushing and monitoring, and there was no consistent documentation of dressing changes or catheter measurement. The ADON and DON confirmed the expected monitoring and documentation requirements, and the DON stated that if it was not documented, it was not done.
Undated oxygen tubing was observed for two residents receiving continuous oxygen via NC at 3 L/min. One resident had acute respiratory failure with hypoxia and the other had COPD and was on hospice; both had severely impaired cognition and orders for weekly oxygen tubing changes. An LN and the DON stated the tubing should be dated to help prevent infection and contamination.
A resident with intact cognition and a pressure ulcer reported difficulty getting pain meds over the weekend, stating she last received them on Friday and had pain all over her body that limited her crocheting. Staff confirmed the resident missed a dose because the medication had not been delivered, and the DON stated LNs were expected to notify the physician if no OTC pain med was available and to ensure pain meds were available to manage pain.
A resident with HTN had ordered hold parameters for atenolol and lisinopril, but MAR review showed multiple doses were given despite HR below 60 and, for lisinopril, despite BP and/or HR being below the ordered limits. The CP stated the lisinopril dose should be held if either threshold was below range, and the DON verified the medications were administered despite the hold parameters; the facility P&P required medications to be accurately administered as ordered.
Medication administration errors resulted in a 10% error rate during observation. An LPN failed to flush a resident’s G-tube before and between enteral meds despite an order for 50 mL water flushes, and another nurse did not administer an ordered Vitamin D dose because it was not in stock and also missed an ordered carvedilol dose. The DON confirmed the flush should have been done and stated residents should not be without their medications.
Contaminated food items were observed in the produce walk-in refrigerator, including two packs of strawberries with white porous material and a jar of Caesar salad dressing with sticky material around the edges. The CDM stated the strawberries would be discarded and noted staff should have rotated the produce; the CDM also directed a dietary aide to clean the dressing jar and stated food containers should have been kept clean to avoid contamination.
Resident Belongings Searched Without Permission, Causing Distress
Penalty
Summary
Facility staff searched a cognitively intact resident's personal belongings without obtaining her permission, violating her right to be treated with respect and dignity and to retain and use personal possessions. The resident, who had aphasia and right-sided weakness due to a stroke and a BIMS score of 13/15 indicating she was cognitively intact, was admitted earlier in the month. During an onsite investigation related to a previously reported motor vehicle accident involving the resident and her significant other, surveyors observed the resident in the courtyard attempting to communicate with a male CNA, who later returned with paper and pen for written communication, which the resident refused. Later that morning, the resident's roommate reported that a female and a male staff member had been searching the resident's personal belongings in their shared room. Following this report, the resident was observed shaking her head, grimacing, placing her hand on her forehead, repeating "no" and "why," and moving anxiously in her wheelchair. The CNA and the Social Services Director acknowledged they had searched the resident's belongings in an effort to locate her communication device and admitted they should have obtained the resident's permission before doing so. The resident stated she felt disrespected by the search. Facility leadership confirmed that staff are expected to obtain resident permission before searching personal belongings, and the facility's resident rights policy states that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.
Failure to Care Plan for Resident Safety While Out On Pass After Motor Vehicle Accident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a care plan addressing a resident’s safety while Out On Pass (OOP) following a motor vehicle accident (MVA) that occurred during an OOP. The resident had been admitted with aphasia and right-sided weakness due to a stroke, and a recent MDS showed a BIMS score of 13/15, indicating intact cognition. During an interview in the courtyard, the resident reported that her significant other (SO) had been driving at the time of the MVA, stated that the SO had a history of seizures and was on medication, and expressed feeling scared about the accident and that the SO should not drive her anymore. Emergency room records documented that the resident was a passenger, that the driver fled the scene, and that the resident sustained no injuries and was safe for discharge. The facility’s IDT documentation showed that the resident did not return within the allowed OOP time and that the facility learned from the emergency room that the resident had been in an MVA, with the resident returning to the facility afterward. The IDT record noted recommendations for a care conference with the resident and her SO, but there was no recommendation to develop and implement a care plan for OOP safety. The charge nurse acknowledged that the existing care plan did not address protection from potential future MVAs with the SO and stated that nursing staff had discussed that the SO should no longer drive the resident, but this was not incorporated into the care plan so all staff would be aware. During interviews, leadership staff, including the administrator and ADON, stated that the SO should not drive the resident for safety, and that this should have been included as an intervention in the resident’s care plan, confirming that no such care plan intervention had been developed or implemented.
Failure to Implement Effective, Individualized Fall Prevention After Repeated Falls
Penalty
Summary
The deficiency involves the facility’s failure to implement new, effective fall prevention measures after each fall incident for two residents with severe cognitive impairment and known fall risk. For the first resident, who had dementia, Parkinson’s disease, a BIMS score of 0, and no decision-making capacity, surveyors documented 13 separate falls over several months in various locations including her room, the hallway, and the dining room. Although some new interventions were occasionally added to the care plan after certain falls—such as lowering the bed, moving the resident closer to the nurse’s station, adding floor mats, consulting PT and pharmacy, increasing monitoring, and ordering a scoop mattress—several falls had no new interventions documented, and causative factors were not consistently identified. At the time of observation, the resident’s room displayed a gold star indicating fall risk, but she was not wearing the required yellow wristband, and a fall mat was leaning against the wall rather than in use. Staff interviews further showed gaps in awareness and understanding of the resident’s fall history and underlying conditions. The DON stated that all falls were tracked and discussed with leadership but was not aware of how many falls this resident had sustained. Nursing staff, including LNs and CNAs, acknowledged that the resident had fallen multiple times but underestimated the number of falls, with some believing she had fallen only two to three times. Several staff members, including CNAs and an LN, reported difficulty working with the resident, described her as not listening, and were unsure of her diagnosis or why she behaved as she did, despite prior dementia education. One CNA and one LN suggested that 1:1 supervision might have helped prevent further falls, and staff reported that the resident fell more often when her family member was not present. The second resident also had a history of falls, encephalopathy, dementia, brain injury, and severely impaired cognition, with a BIMS score of 7. This resident experienced at least 13 falls, most occurring in or near his bed, often at night or in the early morning, and sometimes associated with injuries such as bleeding from a dislodged Foley catheter, a reddened area on the lower back, a hip bruise, and a skin tear. While some new interventions were added after certain falls—such as ensuring the bed was in the lowest position, increasing visual checks, offering toileting, obtaining a pharmacist consult, scheduled toileting, a psychiatric evaluation, moving the resident closer to the nurse’s station, ordering lab tests, a scoop mattress, positioning the bed against the wall, and getting the resident up in a wheelchair during the day—multiple falls had no new fall-preventive measures documented. During observation, this resident’s room also had a gold star indicating fall risk, but he was not wearing the yellow wristband that staff, including CNA 4 and the DON, stated should be used to identify residents at risk for falls. Across both residents, the facility’s own policies required observation for the cause of each fall and initiation of individualized interventions. However, the COC forms and care plans did not consistently document causative factors, times, or locations of falls in sufficient detail to identify trends, and new interventions were not implemented after every fall. The DON later acknowledged that the COCs should have included more information to identify trends and that care plans should be updated to meet individual needs. The Medical Director stated that all falls were discussed in QAPI with a goal to reduce falls, and agreed that earlier use of interventions such as scoop mattresses or 1:1 supervision could have prevented injuries. Despite these processes, the two residents continued to experience repeated falls, and required fall-risk identifiers, such as yellow wristbands, were not consistently in place as observed by surveyors.
Failure to Maintain Individualized, Updated Fall-Prevention Care Plans for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise comprehensive, resident-centered fall prevention care plans with specific, measurable interventions for two residents with severe cognitive impairment and documented fall histories. For the first resident, who had dementia, Parkinson’s disease, a BIMS score of 0, and no capacity to make decisions, the record showed at least 13 falls over several months in various locations including the room, hallway, and dining room. After each fall, Change in Condition Evaluations and care plan entries documented limited or repetitive fall prevention measures such as lowering the bed, moving the resident closer to the nurse’s station, adding floor mats, consulting PT, pharmacy, or RNA, and offering toileting or increased monitoring. Several falls (including those on 8/11/25 and 11/14/25) had no new fall-preventive interventions added to the care plan. Despite multiple falls and a serious injury event on 2/1/26 that resulted in facial fractures and a broken rib, the care plan revisions did not reflect detailed, individualized strategies tied to identified causes or patterns of the falls. Staff interviews and observations further demonstrated gaps in care planning and staff awareness for this resident. The DON stated she was not aware of how many times the resident had fallen, although she reported that the IDT met after each fall to assess patterns and update the care plan. Nursing staff and CNAs acknowledged that the resident had fallen multiple times, but several were unsure of the exact number of falls, the resident’s diagnoses, or the specific care plan interventions. One nurse stated that dementia was probably the reason the resident tried to get up without assistance and commented that a 1:1 might have worked to prevent more falls, while another nurse said they were “trying everything” but it was not effective. CNAs reported relying on verbal report and morning huddles rather than reviewing care plans, and some did not know the resident’s diagnosis of dementia despite having received general dementia education. Observations showed the resident near the nurse’s station with a gold star posted outside the room but without a colored wristband, and fall equipment such as a fall mat leaning against the wall rather than in use. For the second resident, who had encephalopathy, dementia, brain injury, a history of falling, and a BIMS score of 7, the facility documented at least 13 falls or injury events, most occurring in or near the resident’s bed, often at night or in the early morning. The care plan was intermittently updated with general interventions such as keeping the bed in the lowest position, increasing visual checks, offering toileting, obtaining pharmacist and psychiatric consults, moving the resident closer to the nurse’s station, ordering lab tests, using a scoop mattress, positioning the bed against the wall, and getting the resident up in a wheelchair during the day. However, multiple falls (including those on 11/6/25, 11/25/25, 12/19/25, and 12/27/25) did not result in any new fall-preventive measures being added to the care plan. Observations showed the resident in bed with the bed low, landing mats in place, and the mattress curved upward, but without the yellow wristband that staff stated should be used to identify residents at risk for falls. A CNA assigned to observe several fall-risk residents stated she knew this resident had fallen before but did not know how many times or whether he had sustained injuries, and she described the gold star and yellow wristband system as important for staff awareness, even though the wristband was not present. The DON later acknowledged that, despite adding interventions, both residents continued to fall and that care plan interventions should be appropriate and individualized, while the facility’s undated "Fall System" document referenced individualized interventions without evidence that such individualized, resident-specific measures were consistently implemented or updated in the care plans.
Ongoing Delays in Call Light Response and Failures in Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to dignity, self-determination, communication, and timely response to call lights. Multiple residents with intact cognition reported prolonged waits, often up to an hour or more, for staff to respond to call lights for medications, toileting, and personal care. One resident with quadriplegia reported routinely waiting an hour or more for call light response and specifically described a 90‑minute wait for medication, stating that long delays in receiving medication or toileting assistance could cause serious complications to her health. Resident Council minutes from October 2025 through February 2026 repeatedly documented resident complaints about delayed call light response, including concerns about registry staff performance, lack of CNA communication during breaks, and difficulty finding available CNAs during some shifts. Another resident admitted for aftercare following joint replacement surgery and needing assistance with personal care reported that she chose to leave the facility AMA due to call light response problems. She described waiting over an hour for a call light to be answered, and when a staff member finally entered her room, the staff member stated they would get her CNA, even though that staff member was actually the CNA assigned to her. This resident’s room was near the nurses’ station, and she reported hearing staff seated for long periods, laughing and talking, while she waited for assistance. A third resident’s family member documented that call lights often took up to 40 minutes for staff to respond and reported observing three CNAs sitting at the nurses’ station while call lights were alarming. When the family member requested assistance, staff frequently stated that the assigned staff person was on break or busy with other residents and that no other staff were available to help. Surveyor observations and staff interviews further demonstrated failures in timely and appropriate call light response and respect for resident dignity. During an observation, an admissions employee walked past an active call light without responding and acknowledged that all staff were expected to answer call lights but admitted she had not done so, stating she had kept another resident waiting about an hour. In another observation, a resident in a wheelchair requested help to use the bathroom; a CNA entered, turned off the call light without addressing or looking at the resident, and stated he could not assist because the resident requested female CNAs, acknowledging he should have left the call light on since he could not provide the requested care. A subsequent CNA arrived and spoke to the resident’s private caregiver instead of the resident, later admitting she should have addressed the resident directly and consulted coworkers about the resident’s toileting needs. Additional residents reported that staff routinely turned off call lights and left, with actual assistance often delayed about an hour, and described feeling as though no one could see them or that staff had an attitude when they finally responded. The Activities Director and DON both acknowledged that call light response was an ongoing problem, and the Activities Director stated that additional training and monitoring had not improved the process.
Failure to Provide Ordered Medications and Ensure Timely Pharmacy Delivery
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and administer medications as ordered for a resident admitted with diabetes, hypertension, and heart failure. Upon admission, the resident had 14 scheduled medications ordered by the physician as of 11/5/26. Review of the Medication Administration Record (MAR) showed that on 11/6/26, within 24 hours of admission, the resident received only five of the 14 prescribed medications, three of which were supplements and two over-the-counter medications for pain and allergies. The remaining nine medications, including two diabetes medications, three blood pressure medications, a cholesterol medication, a blood thinner, an antidepressant, and eye drops, were not administered. For each of these missed medications, the Licensed Nurse documented that the medications were not available and that the facility was waiting for pharmacy delivery. The resident also had a physician’s order dated 11/5/25 for dulaglutide, a once-weekly injection to control blood sugar, ordered to be given one time a day with no specific day of the week indicated. Nursing notes on 11/6/25 and 11/13/25 documented that the facility was waiting for the pharmacy to deliver this medication, and notes on 11/27/25 and 12/4/25 documented that the medication was not administered without providing any explanation. Over the five-week admission period, the MAR showed five opportunities to administer dulaglutide, but it was given only twice. The DON stated that all medications should be available within eight hours of admission and that if medications were not available, nurses should have notified the DON or Assistant DON to find a solution. The DON acknowledged that although LNs documented that medications were not available, no staff resolved the issue and the medications were not administered as they should have been. Facility policies required ordering medications from the pharmacy with delivery within eight hours of admission and accurate preparation and administration of medications as ordered.
Medication availability, controlled drug documentation, and PRN pain medication administration deficiencies
Penalty
Summary
Pharmacy services were not provided in accordance with accepted standards of practice when a prescribed medication was not available in stock for one resident at the time it was due. During medication administration observation, the nurse stated the resident’s Vitamin D was not available and could not be given because it was a different strength than what was ordered. The resident had an active order for Vitamin D3 125 mcg, which is equivalent to Vitamin D 5000 IU, to be given daily for Vitamin D deficiency. The DON stated it was not acceptable for residents to be without their medications and that residents take medications for a reason. Controlled medication records did not reconcile for four residents receiving PRN controlled medications. For one resident, tramadol was signed out of the CDR on four occasions without corresponding MAR documentation. For another resident, oxycodone was signed out on six occasions without MAR documentation. A third resident had one instance where oxycodone was signed out of the CDR but not documented on the MAR, and a fourth resident had one instance where hydrocodone-acetaminophen was signed out but not documented on the MAR. The DON confirmed the missing MAR documentation and stated controlled medication administration should be documented properly on both records. Controlled pain medications were also administered when the documented pain level did not meet the ordered parameters for two residents. One resident received hydrocodone-acetaminophen multiple times even though the recorded pain levels were below the ordered threshold for severe pain. Another resident received oxycodone on multiple occasions when the pain level was documented as 0. The consultant pharmacist stated there was no reason to give oxycodone if there was no pain, and the DON confirmed the medication had been given when the pain level was 0 on several occasions.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified regarding the development and implementation of a complete care plan for a resident. The care plan did not address all of the resident's needs, and it lacked measurable timetables and specific actions. This failure resulted from incomplete assessment and planning, as the care plan did not comprehensively cover the resident's requirements as observed by surveyors.
Dignity and Feeding Assistance Concern
Penalty
Summary
The facility failed to ensure dignity and respect were provided for one resident during lunchtime when a CNA stood over the resident while assisting with and feeding the meal. The resident was in bed with the lunch tray at the bedside table, and the CNA was standing while feeding the resident rather than being at the resident’s level. A folded metal chair was observed by the wall, and the CNA was not positioned level with the resident during the meal. The resident involved was readmitted to the facility with diagnoses including paraplegia and blindness. The CNA stated the resident was confused, blind, and dependent on staff for all ADLs, and acknowledged that he should have sat down to be at the resident’s level for dignity and safety. Another CNA stated staff needed to sit close to the resident and explain what food was being offered first because the resident could not see, and the DON stated the expectation was for staff to sit with residents and take their time while assisting and feeding them. The facility policy titled Dining Services and Meal Serving stated staff should allow residents plenty of time to eat and sit next to residents requiring physical assistance with feeding.
Failure to Develop Baseline Care Plans for Catheter, Pain, and Oxygen Needs
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with a urinary catheter. Resident 10 was admitted with a urinary catheter, had an H&P indicating he was alert and oriented, and had an MDS showing a BIMS score of 14/15 with intact cognition. During observation, he was found lying in bed with the urinary catheter attached to the bed rails. Review of the TAR showed incomplete documentation for catheter care, and staff interviews confirmed catheter care was performed by CNAs. The LN stated there was no initial care plan for the urinary catheter, and the DON also stated she did not see a baseline care plan for this need. The facility also failed to develop a baseline care plan for pain management for a resident with pain needs. Resident 72 was admitted with a diagnosis that included a pressure ulcer of the right buttock, had an H&P indicating decision-making capacity, and had an MDS BIMS score of 15/15. During interview, Resident 72 stated she had pain all over her body, had difficulty getting pain medication over the weekend, and was unable to do her favorite activity of crocheting. She stated she informed the assigned LN but did not receive the pain medication, and she was told she could not get an OTC pain medication because there was no physician order. The LN stated Resident 72 missed a pain medication dose over the weekend, that emergency meds could be used when pharmacy delivery was delayed, and that no care plan had been developed for pain management. The DON also stated she did not see a baseline care plan for pain management. The facility further failed to develop a baseline care plan for oxygen use for a resident requiring supplemental oxygen. Resident 81 was admitted with acute respiratory failure with hypoxia, and an observation showed oxygen via nasal cannula at 3 liters per minute. Resident 81 stated she used oxygen almost 24 hours a day because she could not breathe without it. Her MDS showed a BIMS score of 05, indicating severe cognitive impairment. Review of the medical record found no baseline care plan for oxygen use, and the LN confirmed there was no care plan regarding oxygen in the record. The DON stated the care plan is important because it outlines the resident’s specific healthcare and support needs and communicates those needs to staff.
G-tube Medications Given Without Required Flushing
Penalty
Summary
The facility failed to provide medication therapy in accordance with professional standards of practice for one sampled resident with a gastrostomy tube. Resident 58 was admitted with diagnoses including encounter for attention to gastrostomy and had an active order for a 50 mL flush with water before and after G-tube medication administration. During a medication administration observation, Licensed Nurse 11 prepared and administered two medications through the resident’s G-tube: Prevacid SoluTab 30 mg and a multivitamin with minerals oral tablet. The nurse administered each medication separately, but no flushing was observed before the first medication or between the two G-tube medications. After the two medications were given, the nurse stated he would do a flush with 60 mL of water. On interview the next day, the nurse confirmed he did not flush before or in between the G-tube medication administration and stated there should be a flush before every medication, after every medication, and in between. The DON also confirmed there should have been a flush before medication administration and stated the resident had an active order for a 50 mL flush before and after G-tube medication administration. The facility policy required flushing the tube with water before and after as ordered and in between each medication as ordered.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide routine nail care to Resident 48, who was admitted with diagnoses including stroke and had altered mental status noted in the history and physical. The resident’s MDS indicated a BIMS score of 12/15, moderate cognitive impairment, upper extremity impairment, and a need for staff assistance with ADLs. During observation, Resident 48 was found in bed with long fingernails on the right hand, and he stated he wanted his fingernails cut because they were long. He reported that he had asked staff about it and was told it needed a special person to cut it. He also stated he could cut the left-hand fingernails but needed help with the right hand because his left arm was weak. Further observation and interviews confirmed the fingernails remained long and sharp. A CNA stated the resident’s right-hand fingernails needed trimming and could potentially cause him to cut or hurt himself, and that keeping fingernails cleaned and trimmed was important for hygiene and infection control. An LN stated the fingernails should have been trimmed short to prevent injury and infection because bacteria could get into the skin when the resident scratched himself, and that CNAs could trim the fingernails since the resident was not diabetic. The DON stated the resident had episodes of confusion and left arm weakness, and that staff were expected to provide nail care because it was important for hygiene and infection control. The facility policy stated residents unable to carry out ADLs would receive necessary services to maintain grooming and personal hygiene.
Failure to Offer Individualized Activities
Penalty
Summary
The facility failed to provide individualized therapeutic and/or social activities according to Resident 40’s plan of care. Resident 40 was admitted with diagnoses including hemiplegia and hemiparesis, and the record review showed he had decision-making capacity, a BIMS score of 15/15, and functional impairments that required staff assistance with ADLs and transfers. During observation, he was found lying in bed watching television and stated he had been in the facility for almost two months, was always in bed, and was bored. He said he wanted to attend activities but staff did not take him out, and he stated he needed help getting up and out of bed. On follow-up, Resident 40 again stated he just lay in bed and staff did not offer to get him up or to attend activities, even though he received the activity sheet. CNA 2 stated he wanted to get up but did not have his own wheelchair. CNA 3 stated he required a mechanical lift to transfer from bed to wheelchair and did not have his own wheelchair; she also stated she did not remember offering him activities and said she should have offered him to attend activities to prevent boredom, bedsore, and depression. LN 1 stated she was not aware he wanted to attend the activity program and that staff should have offered him the activity program so he was not confined to his room and did not feel boredom. The DON stated the expectation was for staff to offer him leisure activities to enjoy his stay and promote emotional well-being.
Unlabeled Tube Feeding Formula
Penalty
Summary
The facility failed to ensure that a tube feeding formula was labeled for one of one resident reviewed for parenteral nutrition. Resident 58 was admitted with diagnoses including malignant neoplasm of the tongue, and the admission record and H&P indicated the resident was alert and oriented to person, place, and time. The MDS dated 7/21/25 indicated the resident had a BIMS score of 8/15, showing moderately impaired cognition, and also indicated the resident was on a feeding tube upon admission. During an observation and interview in the resident’s room, Resident 58 had a gastrostomy feeding tube with formula in the pump machine, and the tube feeding formula was not labeled. The resident stated she had cancer of the tongue and was placed on tube feeding, and she did not know when the tube feeding was administered. The MDS Nurse stated the tube feeding was not labeled and dated, and that the Licensed Nurse who administered it should have labeled and dated the tube feeding and the water flush. The Licensed Nurse stated the process when administering tube feeding was to label the tube feeding and water flush to ensure it was the right resident, the right amount, and when it was administered. The DON stated the expectation was for nurses to label the tube feeding and water flush with the resident’s name, flow rate, time, and date to ensure the resident was receiving the appropriate amount of hydration and nutrition and prevent further weight loss.
Inconsistent Midline Catheter Care and Documentation
Penalty
Summary
The facility failed to provide consistent care and treatment for a resident with a midline catheter in the right arm. The resident was admitted with diagnoses including chronic kidney disease and had intact cognition with a BIMS score of 15. During observation, the resident had a midline catheter with an unclear dated transparent dressing and stated the catheter had not been flushed for a few days and that no one had changed the dressing since it was last done. The resident also stated she had been asking licensed nurses whether the catheter was still needed after completing antibiotic treatment for a UTI, but nothing had been done. Record review showed orders to flush the midline with 10 mL NS before and after IV medications and IV fluids, flush unused ports with 10 mL NS, monitor the site every shift for signs and symptoms of infection or infiltration, and change transparent dressings every 7 days and as needed. The MAR contained missed or blank documentation for flushing and monitoring on multiple dates and shifts, and the dressing was documented as changed only once as needed, with no other record of dressing changes or catheter measurement. The ADON stated nurses were to monitor the site every shift, and the DON stated the dressing changes needed catheter measurement to prevent migration and ensure placement, but the order summary did not include measurement orders. The DON also stated that if it was not documented, it was not done.
Undated Oxygen Tubing for Two Residents
Penalty
Summary
The facility failed to ensure oxygen tubing was dated for two residents who were receiving oxygen therapy. Resident 81 was admitted with acute respiratory failure with hypoxia and was observed on the initial tour with a nasal cannula delivering oxygen at 3 liters per minute via an oxygen concentrator; the oxygen tubing was not dated. Resident 81 stated she used oxygen almost twenty-four hours a day because she could not breathe without it. Her MDS showed a BIMS score of 05, indicating severely impaired cognition, and her order summary directed that oxygen tubing be changed weekly on Fridays. Resident 25 was admitted with COPD and was also observed on the initial tour with a nasal cannula delivering oxygen at 3 liters per minute; her oxygen tubing was not dated. Her order summary showed she was on hospice care for central nervous system lymphoma, and her MDS showed a BIMS score of 03, indicating severely impaired cognition. Her order summary also directed that oxygen tubing be changed weekly on Fridays. During interviews, an LN stated the tubing should have been dated to prevent spread of infection, and the DON stated it was important to date the tubing to prevent infection and contamination.
Missed Pain Medication for Resident with Intact Cognition
Penalty
Summary
Safe, appropriate pain management was not provided for Resident 72, who was admitted with a diagnosis that included a pressure ulcer of the right buttock. The resident’s H&P indicated she had decision-making capacity, and her MDS showed a BIMS score of 15/15, indicating intact cognition. During an interview on 8/25/25, Resident 72 stated she had problems getting her pain medications over the weekend, said she last received pain medication on 8/22/25, and reported pain all over her body that prevented her from doing her favorite activity, crocheting. She also stated she told the assigned LN about the pain medication issue but did not receive the medication, and that her sister brought OTC pain medication on 8/24/25 because she had not received any from the facility. Staff interviews and record review confirmed the missed pain medication. CNA 3 stated Resident 72 was alert and oriented and asked for pain medication when due. LN 1 stated Resident 72 could make her needs known, usually received pain medication daily, and missed a dose over the weekend because the medication had not been delivered; LN 1 also stated the last dose was given on 8/22/25 and the medication was not delivered until 8/26/25. LN 1 stated the facility used emergency kit medications when pharmacy delivery was delayed. The DON stated the expectation was for LNs to notify the physician if there was no OTC pain medication for Resident 72 and to ensure pain medications were available to manage her pain. The facility policy titled Physician Orders stated drugs shall be administered upon written order of a duly licensed person.
BP Medication Hold Parameters Not Followed
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary drugs when ordered BP and HR hold parameters were not followed for atenolol and lisinopril. Resident 72 had an active order for atenolol 50 mg, 1.5 tablets by mouth twice daily for HTN, with instructions to hold if HR was less than 60, yet doses were administered on multiple occasions when the resident's HR was documented below 60. The resident also had an active order for lisinopril 5 mg by mouth daily for HTN, with instructions to hold for SBP less than 110 and HR 60, yet doses were administered on several occasions when the resident's BP and/or HR were below the ordered parameters. During interview, the CP stated that if either the SBP or HR fell below the threshold, the lisinopril dose should be held. The DON verified the instances when BP medications were given despite the hold parameters and stated it was not appropriate to give BP medications despite the hold parameters because the dose is made to maintain BP and HR at a certain level. The facility policy and procedure stated medications are to be accurately administered as per physician's order.
Medication Administration Errors
Penalty
Summary
The facility had a medication error rate of 10% after three medication errors were identified out of 30 opportunities during medication administration observations for two residents. During an observation for one resident with a G-tube, a nurse prepared and administered Prevacid SoluTab 30 mg and a multivitamin with minerals tablet through the tube without flushing before the medications or between them. The nurse later stated he did not flush before or in between the G-tube medications, and the DON confirmed there should have been a flush before medication administration. The resident had an active order for a 50 mL water flush before and after G-tube medication administration, and the facility policy required flushing the tube with water before and after as ordered and in between each medication as ordered. During another observation, a nurse administered 11 medications to a resident but did not give the resident’s ordered Vitamin D 5000 IU because it was not in stock and she stated she could not give it because it was a different strength. The nurse also did not administer carvedilol during the observation, later stating she did not give it and would give it later. The resident had active orders for Vitamin D3 125 mcg daily and carvedilol 6.25 mg twice daily. The DON stated it was not acceptable for residents to be without their medications, and the facility policy required medications to be accurately prepared, administered, and documented as ordered.
Contaminated Food Items Found in Produce Refrigerator
Penalty
Summary
The facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations when food items were found with visible contamination. During an observation of the produce walk-in refrigerator with the Certified Dietary Manager, two packs of strawberries were seen with white porous material on them, and a jar of Caesar salad dressing had sticky material around the edges of the jar. During a later interview with the CDM in the presence of the Registered Dietitian, the CDM stated the strawberries would be discarded and that staff should have rotated the produce. The CDM also asked a dietary aide to clean the edges of the salad dressing jar and stated the food containers should have been kept clean because they could potentially contaminate the food and would not be good for food consumption. The facility policy on refrigerated storage stated produce should be rotated to assure fresh product is used and may be kept longer only if there are no visible signs of spoilage.
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What surveyors actually found near you
We read the 493 citations issued within 25 miles in the last 12 months — including the 3 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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arroyo Vista Nursing Center | 1.8 mi | ★★★★★ | 7 | 0 |
| Brighton Place San Diego | 2.3 mi | ★★★★★ | 3 | 0 |
| St. Pauls Health Care Center | 2.6 mi | ★★★★★ | 9 | 0 |
| Balboa Nursing & Rehabilitation Center | 2.8 mi | ★★★★★ | 7 | 0 |
| Castle Manor Nursing & Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.