Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden San Andreas Care Center during CMS and state inspections, most recent first.
Failure to Individualize Fall Care Plan After Wheelchair Falls: A resident admitted for respite care and hospice services, with depression, delusional disorder, and anxiety disorder, fell face first from a wheelchair after pitching forward and striking the head. Staff updated the care plan with alert charting for 72 hours, but the record did not show a resident-specific intervention addressing the wheelchair pitching-forward risk before the resident fell again about two hours later. Interviews confirmed alert charting was a standard post-fall process and did not, by itself, address the resident’s individual fall risk.
A resident admitted for respite care with depression, delusional disorder, and anxiety missed ordered doses of sertraline and Seroquel because the meds were unavailable and staff did not document notifying the MD, hospice team, or pharmacy. Interviews confirmed the doses were charted as refused even though they were not available, and the facility’s policy required timely pharmacy coordination and use of emergency supply when needed.
A facility failed to provide dignified meal service for 13 residents in the assisted dining room when staff served lunch on food trays with plates, glasses, and silverware left on the tray in front of each resident. In the independent dining room, staff removed the items from the trays and placed them directly on the table. A CNA, DSD, and ADM all stated meals should have been served off the tray to promote dignity, a homelike setting, and residents' rights.
Kitchen equipment and food-contact surfaces were not maintained in clean and sanitary condition. Eight sheet pans stored in the ready-to-use area had oil and grease buildup and raised dark brown residue, the convection oven doors had light brown spots and grease residue, the top of the convection oven was dusty and sticky, and the top of the dishwasher had accumulated debris. The CDM, CKs, RD, and DON confirmed the findings and stated that foodservice equipment and non-food-contact surfaces were expected to be kept clean and free of residue and debris.
An LTC facility failed to maintain infection control practices when a resident with an indwelling catheter had the drainage bag and tubing dragging on the floor, several residents using supplemental oxygen had tubing stored on the floor, in a drawer, or wrapped around an oxygen tank, and an LPN did not properly disinfect shared glucometers between resident uses. Pill cutters contained medication residue, and medication carts had visible debris, hairs, and sticky spots. Staff, the DON, and the IP identified these conditions as not clean and inconsistent with infection control practices.
Informed consent was not properly obtained for psychotropic meds for two residents. One resident with depression and intact cognition said no one explained the medication consent or had her sign anything, and another resident with depression, mood disorder, and intact cognition said the same while receiving Remeron and Cariprazine. Staff said the consent form was completed by nursing, printed for the PA to sign, and did not include a place for resident signatures, while the PA said he did not regularly review side effects, risks, or benefits.
A resident with depression, RA, and obesity was prescribed fluoxetine for statements of hopelessness, and staff monitored depression behavior and medication side effects each shift. However, the care plan listed the psychotropic medication and a behavior goal but did not include non-pharmacological interventions, despite facility policy calling for individualized nondrug and pharmaceutical interventions.
Low-air loss mattresses were not calibrated to the current weights of two residents. One resident with a history of TIA, cerebral infarction, cellulitis, and muscle weakness had a mattress set to over 400 lbs despite weighing 114 lbs. Another resident with hemiplegia, hemiparesis, TIA, cerebral infarction, and DM2 had a mattress set to over 380 lbs despite weighing 183.4 lbs. The LPN confirmed the settings did not match the residents’ weights, and the DON stated the pumps should be adjusted per the manufacturer’s guidelines and current weight.
A resident with bipolar and schizoaffective disorder was assessed as needing supervised smoking because she lacked cognitive skill, memory recall, and the ability to store smoking materials properly. Despite this, she was observed in her room holding a lighter and stated she kept her own cigarettes and lighter with her. The AD, CNA, RN supervisor, and ADM all confirmed that supervised smokers should not keep their own smoking supplies and that the items should be secured and only provided during scheduled smoking times.
Medication services were deficient when delivery manifests for prescription and narcotic meds were left unsigned by licensed staff, a resident’s eye drops and another resident’s lactulose were not available when needed, and hazardous drugs in med carts were not consistently labeled. During med pass and cart review, staff could not locate the ordered meds, found the wrong eye drop product, and identified unlabeled HDs such as Megace, finasteride, and Depakote; an LPN stated she did not know what HD meant.
A resident with PE, recurrent DVT, and an active left-leg clot was switched from rivaroxaban to clopidogrel without documented clinical justification. The MAR showed the anticoagulant was stopped and the antiplatelet was started for clot prevention, while the PA acknowledged the drugs were not therapeutically equivalent and the MD and consultant pharmacist stated the change was not a therapeutic interchange and should have been justified.
Unlabeled and Improperly Stored Medications and Sterile Supplies: An insulin glargine pen for a resident was found in a med cart without a pharmacy label, an opened box of dorzolamide-timolol eye drops was stored without an opened date, and a treatment cart contained opened sterile normal saline and an opened single-use foam dressing. The DON, RNS, and TN acknowledged the items were not stored or labeled appropriately, and the eye drops and sterile supplies were no longer in proper condition for use.
Physician orders were not carried out for two residents. One resident with anemia and other chronic conditions had handwritten orders for iron, Vitamin C, and Vitamin B-12 after abnormal CBC results, but staff could not find the orders entered in the EHR. Another resident with a history of blood clots, morbid obesity, and arthritis had a handwritten order to start Zepbound weekly, but there was no documentation that the order was addressed or entered. The PA, MD, DON, and RNS described gaps in how orders were communicated and entered into the medical record.
A resident with parkinsonism, difficulty walking, muscle weakness, and a BIMS score of 9/15 had an activity care plan calling for encouragement and assistance with group or social activities, but the CNA activity documentation did not consistently reflect daily activity participation or visits. The AD confirmed some days showed participation or observation while other days showed no activities provided, even though activities were offered daily and the resident sometimes attended as an observer or spent time with family.
Failure to Report Abuse Investigation Findings: The facility reviewed a resident-to-resident altercation as a potential abuse incident involving two residents, one with depression and the other with Alzheimer’s disease, unspecified psychosis, and major depressive disorder. The ADM confirmed the investigation was completed in the incident folder but no follow-up report was submitted to the Department within the required timeframe, despite policy stating resident-to-resident altercations are reviewed as potential abuse and that the Executive Director oversees abuse investigations.
Controlled medication administration was not documented on the MAR for a resident receiving hydrocodone/APAP for pain. An LPN signed out the doses on the controlled drug record but did not record them as administered on the MAR, and later confirmed the omission. The DON stated medications should be documented when given, and the facility policy required documentation on both the accountability record and the MAR.
A resident's medical record was found to have multiple missing CNA documentation entries for ADL tasks across several shifts, including areas such as continence, mobility, hygiene, and fluid intake. Staff interviews confirmed that while care was sometimes provided, it was not always documented as required, and oversight by nursing staff was inconsistent. Facility leadership verified the documentation gaps and acknowledged that the facility's policy requires complete and accurate charting of all care and services provided.
Nursing staff discontinued CPR for a resident with a full code status before EMS arrived and without a physician's order or confirmation of death. Despite facility policy requiring CPR to continue until emergency personnel assume care, staff stopped resuscitation efforts and a nurse declared the time of death. Interviews confirmed that only a physician should pronounce death and that the protocol was not followed.
A resident with a history of aggression and multiple mental health diagnoses was not adequately supervised according to their care plan, which required separation from female residents. Staff were unaware of these care plan instructions, resulting in the resident grabbing another resident's wrist and shirt and attempting to strike her in a hallway. The DON confirmed that the care plan was not fully implemented and one-to-one monitoring was not provided after a prior incident.
Two residents at risk for pressure ulcers did not receive proper assessment, documentation, or implementation of preventative measures, resulting in the worsening of wounds. In both cases, staff failed to consistently turn and reposition the residents, did not document wound changes or interventions, and did not notify the physician when conditions deteriorated. One resident required surgical intervention for a worsened coccyx wound, while the other developed a deep tissue injury on the heel.
The facility did not consistently document or discuss advance directives with residents or their legal representatives, failed to ensure code status orders in the EMR matched POLST forms, and left required sections of POLST forms incomplete. These actions led to residents' treatment preferences not being known or followed, including an incident where a resident received CPR despite a DNR order.
Three residents did not have appropriate care plans developed or implemented: two residents with active MDRO infections were placed on Enhanced Barrier Precautions without corresponding care plans, and another resident with a DNR order had her wishes disregarded when staff initiated CPR. These actions were not in accordance with facility policy requiring comprehensive, person-centered care plans.
Several residents did not receive their prescribed diets, including fortified mashed potatoes for those needing added calories and appropriate finger foods for a resident requiring self-feeding support. Regular menu items were served instead, contrary to dietary orders and facility policy.
Surveyors found multiple deficiencies in food safety and sanitation, including unclean kitchen equipment, improper food labeling and storage, use of expired foods, unsanitary surfaces, and serving food prepared in contaminated pans. The Dietary Manager and Registered Dietician confirmed these practices did not meet professional standards and posed risks of contamination for all residents receiving facility-prepared meals.
Multiple infection control lapses were observed, including a physical therapy assistant not wearing an N95 respirator in a COVID-19 positive resident's room, a CNA transferring a resident on enhanced barrier precautions without a gown, two residents with MDROs not placed on EBP, and a nurse failing to properly disinfect a glucometer between uses by not allowing the required wet contact time. These actions were inconsistent with facility policy and infection prevention protocols.
Three residents were found without access to their call lights, including one with limited mobility whose call light was under pillows, another whose call light was attached to the bottom of the bed rail and out of reach, and a third whose call light was left on a chair. Staff confirmed in each case that the call lights were not accessible and acknowledged the expectation that call lights should always be within reach, as outlined in facility policy.
A resident with a documented DNR status on their POLST received CPR after staff relied on outdated code status information in the EHR, leading to resuscitation efforts that were not in accordance with the resident's wishes. The discrepancy between the POLST and EHR, along with inconsistent staff practices for verifying code status, resulted in the resident receiving care contrary to their documented preferences.
A resident was left without water within reach, despite expressing thirst and showing signs of dehydration such as dry, cracked lips. Both nursing and CNA staff confirmed the water was not accessible, and the care plan required fluids to be available and staff to cue the resident to drink. The facility's hydration policy also mandated bedside water and monitoring for dehydration symptoms.
Two residents received oxygen therapy without adherence to professional standards, including one instance where oxygen was administered without a physician order and both cases lacking required 'oxygen in use' signage outside their rooms. Staff and the DON confirmed these actions were not in line with facility policy, which mandates physician orders for oxygen and proper signage to alert staff and visitors.
A resident with a history of cancer and rheumatoid arthritis experienced unrelieved pain when an LPN failed to apply a physician-ordered Lidocaine patch at the scheduled time, instead documenting it as given and only applying it three hours later. The resident was observed in pain without the patch, and the facility's pain management policy was not followed.
Two residents did not receive medications as prescribed: one had PRN acetaminophen left at the bedside without nurse observation, and another received Sucralfate during a meal instead of before as ordered. Nursing staff acknowledged these deviations from physician orders and facility policy.
A garbage dumpster bin was found with its lid propped open, as confirmed by both the DM and RD, contrary to expectations for proper waste management. This failure to keep the dumpster closed had the potential to attract rodents and insects, affecting the facility's 89 residents.
Two residents were affected by failures in medical record-keeping: one had another individual's lab results mistakenly placed in their file, and another did not have complete informed consent documentation for psychotropic medications, lacking details on frequency, dose, and duration as required by facility policy. The DON confirmed these deficiencies during record reviews and interviews.
A resident with chronic health conditions, including COPD and diabetes, was not offered the PPSV23 pneumococcal booster vaccine despite being eligible and having previously received the PCV13 vaccine. Both the IP and DON confirmed the oversight during interviews, and CDC guidelines reviewed by staff supported the need for the additional vaccination.
A steamer in the kitchen was repeatedly observed leaking water onto the floor, with staff needing to frequently empty an overflowing tray beneath it. The leak persisted despite previous repairs, and no wet floor caution signs were in use. The Dietary Manager confirmed the ongoing issue and acknowledged the risks associated with the wet floor and leaking equipment, which was not maintained as required by facility policy.
A CNA in an LTC facility provided a resident with a vape pen containing THC, despite the resident's history of anxiety and COPD. The resident, who was on supplemental oxygen, used the vape pen after expressing anxiety. Facility policies prohibited staff from providing smoking items to residents, and the CNA admitted to the action. The facility's Administrator and DON acknowledged the policy breach, and the Physician Assistant instructed staff to remove the vape pen and monitor the resident for adverse effects.
A resident at high risk for falls due to Parkinson's disease and muscle weakness fell from bed and sustained injuries because the facility failed to implement care plan interventions, including a fall mat and two-person assistance. The CNA involved was unaware of the care plan requirements, leading to the resident's fall and increased dependency on staff for daily activities.
Failure to Individualize Fall Care Plan After Wheelchair Falls
Penalty
Summary
The facility failed to develop person-centered interventions for a resident’s fall care plan after the resident, who was admitted for respite care while receiving hospice services and had diagnoses including depression, delusional disorder, and anxiety disorder, sustained a witnessed fall from a wheelchair. After the resident was readjusted in the wheelchair and pushed down the hall, she pitched forward, fell face first to the floor, struck the top of her head, and sustained a small cut to the bridge of the nose and a bruise to the forehead. The resident’s fall care plans were revised to include alert charting for 72 hours, but the record did not show that staff identified the root cause of the fall or documented how alert charting addressed the resident’s specific risk of pitching forward from the wheelchair before the next fall occurred. Approximately two hours later, the resident again pitched forward and fell face first to the floor, striking the top of her head. During interviews, the LN stated that alert charting was the facility’s standard process after a fall but could not explain how it reduced the resident’s risk of another similar fall. The RN supervisor verified the care plan was updated to include alert charting and stated she was unsure whether the intervention was effective in preventing the second fall. The DSD stated care plans were to be resident-specific and person-centered, and that alert charting was a general post-fall intervention that did not address the resident’s individual fall risk. The facility policy stated the center implements a fall management plan based on medical history review and resident evaluation and updates care plans with individualized interventions in an attempt to reduce or prevent falls.
Missed Psychotropic Medications Due to Delayed Coordination
Penalty
Summary
The facility failed to ensure timely procurement and administration of physician-ordered medications for one resident admitted for respite care with diagnoses including depression, delusional disorder, and anxiety disorder. The resident had orders for Sertraline 50 mg daily for crying related to depression and Seroquel 25 mg, 0.25 tablet daily for visual hallucinations related to delusional disorder. The resident did not receive Seroquel on three consecutive days and did not receive Sertraline on two days. During record review, a licensed nurse verified the missed doses and stated the medications had been documented as refused even though they were unavailable at the time. The nurse also acknowledged there was no documentation that the physician, hospice staff, or pharmacy was notified about the missed doses. Additional interviews confirmed staff expected to notify the physician when a medication was unavailable and to notify hospice and pharmacy when the resident was receiving hospice services. The pharmacy consultant verified there was no documentation that staff contacted the physician, pharmacist, or hospice staff regarding the missed doses, and stated missed behavior medications should be administered as soon as possible. Facility policies required timely medication receipt, prompt pharmacy notification when needed before the next delivery, use of emergency supply when applicable, and coordination of hospice-related medications and physician notification.
Dignified Meal Service Not Provided in Assisted Dining Room
Penalty
Summary
The facility failed to provide meal service in a dignified manner for 13 residents during lunch in the assisted dining room. During a concurrent observation and interview, the 13 residents were seated at tables waiting for lunch, and staff served their meals by placing the food trays on the table in front of each resident. All 13 residents received their meals on a food tray, with the plates, glasses, and silverware left on the tray while they ate. In contrast, during an observation in the independent dining room, staff removed the food from the trays and set the plates, glasses, and silverware directly on the table in front of each resident. A CNA stated meals were served this way only in the assisted dining room and that residents in the independent dining room had their meals removed from the tray. The DSD and Administrator both stated meals should have been served off the tray to promote dignity, a homelike environment, and residents' rights.
Kitchen Equipment and Food-Contact Surfaces Not Kept Clean
Penalty
Summary
Food preparation equipment and food-contact surfaces were not maintained in clean and sanitary condition. During an initial kitchen tour, 8 large sheet pans stored in the ready-to-use area were observed with oil and grease buildup throughout the interior surfaces and raised dark brown residue along portions of the inner rims. The Certified Dietary Manager confirmed the findings and stated the pans were being used as trays to hold salads and desserts, while also noting that if they were used for cooking, the residue could chip off and fall into food. The same pans were later observed still stored in the ready-to-use area, and kitchen staff confirmed they should not have been kept there because residue could chip off into food during use. The interior surfaces of the convection oven doors were observed to have multiple light brown spots and accumulations of oil and grease residue. The Certified Dietary Manager stated the oven was old and began scrubbing the interior door surfaces during the observation, but was unable to remove all of the buildup. The Director of Nursing later stated that some sheet pans and the convection oven were old and had been in use for an extended period, which could result in residue accumulation over the years. The Registered Dietitian stated that dietary staff were expected to thoroughly clean the interior surfaces of the convection oven doors at the end of each shift and that food preparation equipment should always be maintained in a clean and sanitary condition. The top of the convection oven was observed covered with dust and sticky to the touch, and the top of the dishwasher had a large accumulation of debris on the right side where clean dishes exited after the washing process. Staff confirmed that dietary aides were expected to clean these surfaces after use and that visible debris, food particles, and mineral deposits should not remain because they could fall onto clean dishes or food. The facility policy stated that all foodservice equipment would be clean, sanitary, and in proper working order, that food contact equipment would be cleaned and sanitized after every use, and that non-food contact equipment would be clean and free of debris.
Infection Control Lapses With Oxygen Equipment, Catheter Care, Glucometer Disinfection, and Medication Cart Cleanliness
Penalty
Summary
The facility failed to ensure safe infection prevention and control practices for residents who used supplemental oxygen. Resident 14, who had dependence on supplemental oxygen, was observed with oxygen tubing wrapped around an oxygen tank on the wheelchair and later with the entire tubing on the floor while connected to an oxygen concentrator. Resident 65, who had dependence on supplemental oxygen and COPD, was observed with oxygen tubing placed inside the nightstand drawer while the concentrator was running. Resident 8, who had dependence on supplemental oxygen and COPD, was observed with oxygen tubing on the floor next to the bed while connected to the resident’s nose. Staff members and the DON stated the tubing should not be on the floor and should be stored in a bag when not in use. Resident 11, who had an indwelling urinary catheter and diagnoses including obstructive and reflux uropathy, was observed wheeling herself in the hallway with the catheter bag and part of the tubing hanging under the wheelchair and touching the floor. The IP confirmed the tubing and drainage bag were dragging on the floor and stated they should not touch the ground. The resident’s care plan identified a potential for infection related to the indwelling catheter and directed staff to monitor placement and positioning of the catheter and provide catheter care every shift. Facility staff described catheter care as including proper placement of the drainage bag below the bladder and securing the tubing, and the facility’s in-service training stated catheter bags need to be below the bladder and placed in a privacy bag with tubing and bag not on the floor. During medication administration, an LPN used shared glucometers for Resident 98 and Resident 100 and, after each use, wiped the outer surface with one bleach wipe while bare-handed and kept the device wrapped on the cart. The LPN acknowledged she did not clean and sanitize the glucometer as she had been trained to do. The facility’s policy and the manufacturer’s instructions required cleaning and disinfection between each resident use. In addition, pill cutters stored in the medication cart contained visible white and yellow medication residue, and medication carts were observed with visible dark specks, debris, fine hairs or fibers, and sticky spots. Staff, the DON, the RNS, and the IP all identified these conditions as not clean and as an infection control concern.
Informed Consent for Psychotropic Medications Not Obtained
Penalty
Summary
The facility failed to ensure informed consent was obtained for psychotropic medication use for two residents. Resident 1 had diagnoses including depression and a BIMS score of 13, indicating cognitive intactness, and stated during interview that no one talked to her about medication consent and that she did not sign anything. Resident 1 also recalled an older man coming to her room, listening to her heart, and leaving without asking questions or giving comments. Resident 3 had diagnoses including depression, mood disorder, morbid obesity, and arthritis, and a BIMS score of 15. Her MAR showed she was receiving two mind-altering drugs, Remeron (Mirtazapine) and Cariprazine (Vraylar). During interview, Resident 3 stated no one talked to her about medication consent and she did not sign anything, and that she had not seen a doctor or anyone explaining her drugs. Staff interviews and record review showed the informed consent forms were completed in the computer by a nurse, printed for the PA to sign, and did not provide a place for residents to sign even when they had full capacity. The PA stated he did not regularly review side effects, risks, or benefits, while the MD stated providers were responsible for giving medication information and discussing it with residents, and that residents should be able to sign the form.
Missing Non-Drug Interventions for Psychotropic Use
Penalty
Summary
The facility failed to implement non-pharmacological interventions in the plan of care for one resident who was receiving a psychotropic medication. Resident 6 was admitted with diagnoses including rheumatoid arthritis, depression, and obesity. The medication record showed fluoxetine 20 mg daily was started for statements of hopelessness related to depression, and nursing staff were monitoring the resident’s depression behavior and Prozac side effects every shift in the MAR. The care plan identified that Resident 6 was taking fluoxetine for depression and had a goal to reduce and manage behaviors, but the interventions section did not include non-drug approaches to address feelings of depression and hopelessness. During interview, the RNS stated non-pharmacological interventions were usually part of the care plan and/or MAR for staff to use and document, and that this may have been missed in Resident 6’s care planning documentation. Staff interviews also reflected that residents benefited from being heard, talked to, given kind gestures, eye contact, and other individualized interactions, and the facility policy required a holistic approach with individualized nondrug and pharmaceutical interventions.
Low-Air Loss Mattresses Not Calibrated to Residents’ Weights
Penalty
Summary
The facility failed to provide adequate care and services to promote healing and prevent pressure injury for two residents who were using low-air loss mattresses. For Resident 25, the record showed diagnoses including a history of TIA, cerebral infarction, cellulitis, and muscle weakness. During observation, Resident 25 was lying in bed on a low-air loss mattress that was set to over 400 lbs, while the resident’s most recent documented weight was 114 lbs. The licensed nurse confirmed the mattress setting did not match the resident’s current weight and stated the mattress should be adjusted according to the resident’s weight. For Resident 56, the record showed diagnoses including hemiplegia, hemiparesis, a history of TIA, cerebral infarction, and type 2 diabetes mellitus. During observation, Resident 56 was lying in bed on a low-air loss mattress set to over 380 lbs, while the most recent documented weight was 183.4 lbs. The licensed nurse confirmed the setting and explained that the mattress was intended to relieve pressure and maintain skin integrity, and that nurses were responsible for adjusting the pump according to the resident’s current weight. The Director of Nursing stated that low-air loss mattress pumps should be adjusted according to the manufacturer’s guidelines and the residents’ current weight. The facility’s low-air loss mattress operator’s manual stated to determine the patient’s weight and set the control knob to that weight setting on the control unit. Resident 25’s Braden Scale score was 18, indicating at risk for pressure ulcer development, and Resident 56’s Braden Scale score was 14, indicating moderate risk for pressure ulcer development.
Supervised smoker kept cigarettes and lighter in room
Penalty
Summary
A safe, hazard-free environment was not maintained for one resident who was assessed as needing supervised smoking. The resident had diagnoses including bipolar disorder and schizoaffective disorder. Her Smoking Safety Evaluation indicated she did not have cognitive skill and adequate memory recall, did not know how smoking materials were to be stored, and could not demonstrate proper storage of smoking materials. The care plan also identified supervised smoking times, and the interdisciplinary team noted that she was safe to smoke with supervision. During observation, the resident was found in her room holding a red lighter in her right hand, and she stated that she kept her own cigarettes and lighter with her in her room. The Activity Director stated that residents who are supervised for smoking do not keep their own cigarettes and lighter, and that this resident's smoking materials should be kept in a box at the activity office and only given during scheduled smoking time. The resident later stated that staff were aware she kept her own cigarettes and lighter and that she used the lighter to light her cigarette. A CNA confirmed the resident had her cigarettes and lighter with her, and the RN supervisor stated the smoking supplies should have been kept in a locked box and not with her. The Administrator stated the resident should not have had the cigarette and lighter with her because it was a safety issue and increased the risk for fire hazards, burns, or death.
Medication Receipt, Availability, and Hazardous Drug Labeling Deficiencies
Penalty
Summary
Pharmaceutical services were not managed to ensure accountability for delivered medications when prescription and narcotic medication delivery manifests from the provider pharmacy were kept in a binder without signatures or dates showing receipt by licensed staff. During review of the consolidated delivery sheets, the signature area for "Checked By," "Received by Print Name," and "Date/Time" was blank, and the RNS stated staff had been signing only the pharmacy driver’s records. The RNS and DON later stated nurses had been instructed to sign the physical delivery sheets, and the pharmacist confirmed the facility should sign the manifest upon receipt. Resident 4 and Resident 24 did not have prescribed medications available at the time of medication administration. During observation, an LPN could not locate Artificial Tears for Resident 4 and had to search the storage room for a replacement supply, but the wrong product, Clear Eyes, was found instead. The next day, the Artificial Tears was still not available, and the LPN stated the doctor needed to be notified. During another observation, an LPN could not find lactulose for Resident 24 and stated a refill needed to be called in; later that day the medication still had not been received, and the next day it remained unavailable. Hazardous drugs stored in the medication carts were not consistently labeled to alert staff for safe handling. In the B wing medication cart, two bottles of Megace were found in the bottom drawer, with one bottle labeled as hazardous drug and the other not labeled; both had reddish-brown sticky spills on the outside. Additional hazardous drugs in bubble packs, including finasteride and Depakote, were also stored without hazardous drug labeling. An LPN stated she did not know what HD meant and followed the MAR order, while the DON and RNS acknowledged the pharmacy was not consistent in labeling medications with HD.
Unjustified switch from anticoagulant to antiplatelet therapy
Penalty
Summary
Ensure each resident’s drug regimen was free from unnecessary drugs was not met for one resident with a history of PE, recurrent DVT, immobility, morbid obesity, and chronic knee pain. The resident was admitted with a history of blood clots and later re-admitted to the hospital with another blood clot in the left leg and a hematoma in the left hip and pelvis area after receiving enoxaparin injections. The hospital discharge summary documented a nonocclusive thrombus in the left common femoral area and a left psoas hematoma without active bleeding, and the discharge plan directed continuation of rivaroxaban 15 mg twice daily with meals. The medication record showed rivaroxaban 20 mg daily, then enoxaparin injections, then rivaroxaban 15 mg twice daily, followed by rivaroxaban being marked out of order for several days. During that time, clopidogrel 75 mg daily was started for blood clot prevention related to the resident’s personal history of PE. The record did not contain a provider note or clinical justification for changing rivaroxaban to clopidogrel. During interview, the nurse supervisor stated the order was entered as a verbal order and later co-signed by the PA. The PA stated he authorized the change from rivaroxaban to clopidogrel, said both drugs accomplished the same end results with less bleeding based on his experience, and acknowledged he knew the drugs were not therapeutically equivalent and served different indications. The medical director stated the two drugs were very different and that risk versus benefit and clinical justification should have been documented. The consultant pharmacist stated the drugs were in different classes and that for an active and recurrent blood clot, an anticoagulant was recommended; the pharmacist did not know why the change was ordered.
Unlabeled and Improperly Stored Medications and Sterile Supplies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled and stored in the medication and treatment carts. During observation in the C wing, an insulin glargine pen for Resident 100 was found in the medication cart without a pharmacy prescription label; the resident’s name had been handwritten on the pen with a permanent marker, and the Ziplock bag used to store the medication was missing from the cart. The Licensed Nurse stated she was not sure why the insulin pen did not have a patient label, and the Registered Nurse Supervisor stated residents should have their own insulin pen with a pharmacy label and that she would not administer an unlabeled insulin pen because of medication error and infection control concerns. In the B wing medication cart, an opened box of Dorzolamide-Timolol ophthalmic solution was found out of its foil wrap without any marking showing when it had been opened. The nurse who inspected it stated she was unsure when the medication pouch had been opened. The manufacturer’s instructions on the box stated to throw away any unused single-use containers 15 days after first opening the pouch. The Registered Nurse Supervisor stated she thought the eye drops were individually packaged and acknowledged that use beyond the manufacturer’s 15-day beyond-use date after opening the pouch could result in reduced effectiveness. At the main station treatment cart, two opened bottles of sterile normal saline and an opened single-use Soft Foam Dressing were stored in the active storage areas of the cart. The Registered Nurse Supervisor stated the dressing was sterile and should not be used, and that the saline should have been discarded after one-time use. The Treatment Nurse stated she did not know why the opened saline bottle and opened single-use silicone foam dressing were kept in the treatment cart and confirmed they were not supposed to be kept there because they were no longer sterile and posed a risk of infection.
Physician Orders Not Carried Out for Two Residents
Penalty
Summary
The facility failed to carry out physician orders for two residents reviewed for unnecessary drugs. One resident had diagnoses including anemia, low thyroid level, depression, high blood pressure, and a fracture of the thighbone. A review of the resident’s CBC dated 3/10/26 showed low hemoglobin and other abnormal anemia-related markers, and the paper record contained handwritten orders for an iron pill, Vitamin C, and Vitamin B-12 signed by a PA. During interview and record review, the RNS stated she could not find any corresponding orders entered into the electronic health record and was unsure why the orders were not communicated to nursing staff for entry. The PA stated he signed the paper sheet and wrote the orders on the lab sheet, did not enter orders into the computer, and was not sure why the orders were not carried out. The MD stated providers had access to the facility computer system and that it was a shared responsibility to ensure orders were entered timely. A second resident had a history of blood clots, morbid obesity, and arthritis. In the resident’s H&P dated 4/29/26, MD 2 wrote a handwritten order to start Zepbound 2.5 mg weekly. Review of the electronic record, including nursing notes and provider follow-up notes, did not show that the order was addressed or carried out. The DON and RNS stated they could not find documentation that the Zepbound order was entered, and the RNS said nursing staff did not see the new order listed at the bottom of the H&P sheet to address and input into the computer. The MD again stated providers had access to the computer system and could enter orders, and that it was a shared responsibility to ensure orders were entered in the medical record in a timely manner. The facility did not provide a policy on medical provider and director roles and responsibilities.
Incomplete Activity Documentation for a Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for 1 of 26 sampled residents, Resident 17, because the Documentation Survey Report did not reflect activities provided on a daily basis from 5/1/26 through 5/31/26. Resident 17 was admitted with diagnoses including parkinsonism, difficulty walking, and muscle weakness, and the MDS dated 5/27/26 showed a BIMS score of 9 out of 15, indicating a moderate problem with thinking, learning, and memory. The care plan indicated Resident 17 needed encouragement and assistance to attend group or social activities, and that activity staff would visit to invite, encourage, and assist her to activities she might enjoy. During record review with the Activity Director, the Documentation Survey Report showed activity participation or observation on 5/3/26, 5/4/26, 5/10/26, 5/14/26, 5/20/26, 5/25/26, 5/26/26, and 5/29/26, while the other days reflected no activities provided. The Activity Director stated activities were offered every day for 7 days and that Resident 17 attended group activities as an observer and seldom as a participant, and also spent time with a family member visiting when not in activities. The Activity Director and Administrator stated activities attended, including family visits, should have been documented on the days they occurred, and that when activities were not documented then activities were not done. An observation on 6/10/26 found Resident 17 returned to her room and remained there, and on 6/11/26 she was seated in her wheelchair in front of the aviary dozing off and did not respond to greetings.
Failure to Report Abuse Investigation Findings
Penalty
Summary
The facility failed to report the findings of its investigation to the appropriate parties for an allegation of abuse involving two residents after an altercation between them was reviewed as a potential abuse incident. The Administrator confirmed during interview and record review that the incident folder for the two residents was reviewed, that the altercation occurred, and that no follow-up report was submitted to the Department. The Administrator also acknowledged that the report should have been submitted within five days of the incident and stated that the administrator is ultimately responsible for carrying out investigations and reporting the findings in accordance with required timeframes. Resident 1 was admitted with diagnoses including depression. Resident 2 was admitted with diagnoses including Alzheimer's disease, unspecified psychosis, and major depressive disorder. The facility policy stated that resident-to-resident altercations are reviewed as potential abuse and that the Center conducts a thorough investigation of potential, suspected, and/or allegations of abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal regulations. Another facility policy stated that the Executive Director is the designated abuse coordinator and is responsible for assigning and overseeing staff who assist with investigations, and that the Center maintains complete and thorough documentation of the investigation.
Controlled Medication Administration Not Documented
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to document the administration of controlled drugs for one sampled resident. Resident 5 was admitted with diagnoses including low back pain and had hydrocodone/APAP prescribed for pain management. A review of the resident’s ANTIBIOTIC OR CONTROLLED DRUG RECORD and MAR showed that doses of hydrocodone/APAP were signed out by a licensed nurse on 5/13/26 at 8 PM, 5/25/26 at 4 PM, and 5/26/26 at 8 PM, but those doses were not documented as administered on the MAR. During interviews and record review, LN 2 confirmed the doses were signed out on the controlled drug record and not documented on the MAR for those dates. LN 4 also confirmed she signed out the hydrocodone/APAP doses and did not document them on the MAR, stating that Resident 5 usually got anxious when he wanted his medication and that this likely distracted her from documenting the medication as administered. LN 4 stated she should have documented the doses on the MAR so other LNs would not inadvertently administer another dose. The DON stated medications should be documented when given to prevent medication errors, and the facility policy required the licensed nurse to enter the administration information on both the accountability record and the MAR immediately when a controlled medication is administered.
Incomplete CNA Documentation of Resident ADL Tasks
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident when multiple shifts lacked Certified Nursing Assistant (CNA) documentation for various Activities of Daily Living (ADL) tasks throughout July 2024. A review of the resident's clinical documentation revealed missing entries across a wide range of care areas, including behavior, bladder and bowel continence, bowel movements, fall interventions, fluid intake, and numerous GG assessment items such as transfers, hygiene, and ambulation. These omissions were present on multiple dates and shifts, indicating a pattern of incomplete documentation. Interviews with facility staff confirmed the documentation lapses. A CNA acknowledged that there were times when ADL tasks were completed but not documented, despite being aware of the expectation to finish charting by the end of each shift. The CNA also recognized that incomplete documentation could result in miscommunication about the resident's care, such as the risk of unnecessary medication administration. A licensed nurse stated that CNAs were responsible for documenting every shift and that charge nurses were expected to ensure this was done, but admitted that this oversight was not always performed. Further confirmation came from the Director of Staff Development and the Director of Nurses, both of whom verified the presence of multiple missing documentation entries for the resident. They stated that the lack of complete CNA documentation could lead to miscommunication between shifts, difficulty in proving that care tasks were completed, and challenges for other departments in accurately assessing the resident. The facility's policy and procedure on charting and documentation required that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented objectively, completely, and accurately in the medical record.
CPR Discontinued Prematurely Without Physician Order
Penalty
Summary
Nursing staff failed to follow established protocols for the initiation and discontinuation of CPR for a resident with diagnoses including orthopedic aftercare and hypertension. The resident had a valid POLST indicating full code status, meaning all resuscitative efforts were to be made in the event of cardiac or respiratory arrest. When the resident was found unresponsive with no signs of life, the licensed nurse verified the absence of an apical pulse and respirations, and, after confirming the full code status, CPR was initiated. However, CPR was discontinued by the nursing staff before the arrival of EMS, and the time of death was declared by a licensed nurse without a physician's order or confirmation of death. Interviews with the involved nurses revealed that CPR was stopped because there were no signs of viability, and the nurse believed the resident had already expired. Both the nurses and the Director of Nursing acknowledged that, according to facility policy, only a physician is authorized to pronounce death, and CPR should have been continued until EMS arrived. The facility's policies also required that CPR/BLS be continued until emergency medical personnel assumed care, which was not followed in this instance.
Failure to Implement Supervision and Safety Interventions for Resident with Aggressive Behavior
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for a resident with a history of aggressive behavior. Specifically, a resident diagnosed with Dementia, Paranoid Schizophrenia, and Alzheimer's Disease, who had previously been involved in an incident with another resident, was not kept away from female residents as directed in their care plan. Three days after the initial incident, this resident grabbed another resident's wrist and shirt and attempted to strike her while both were sitting in the hallway. The care plan clearly stated that the resident should be kept away from female residents and not be left alone with them, but this was not followed. Staff interviews revealed that both the licensed nurse and the certified nursing assistant involved were unaware of the care plan instructions regarding the resident's required separation from female residents. The Director of Nursing acknowledged that the care plan was not fully implemented and that the resident was not placed on one-to-one monitoring after the first incident. This lack of communication and supervision allowed the incident to occur, potentially affecting the physical and psychosocial well-being of the resident who was grabbed.
Failure to Prevent and Manage Pressure Ulcers Due to Incomplete Assessment, Documentation, and Implementation of Preventative Measures
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for two residents who were at risk for pressure injuries. One resident was admitted with a shearing wound on the coccyx and was assessed as being at risk for pressure ulcers. However, the initial skin assessments and wound documentation were incomplete, and the physician was not notified when the wound worsened. Preventative measures, such as turning and repositioning every two hours, were not properly identified or implemented upon admission. The nurse responsible for wound care did not document wound measurements, location, or description after the initial assessment and admitted to missing required charting. There was also no evidence that the resident was turned every two hours or that refusals were documented. As a result, the resident's wound worsened, causing pain and requiring surgical intervention and wound vacuum placement at a hospital. Another resident, also at risk for pressure ulcers due to immobility and incontinence, developed a shearing wound on the coccyx and blanchable redness on both heels while in the facility. The skin assessments and wound documentation for this resident were incomplete, and interventions to prevent pressure ulcer development, such as turning every two hours and the use of heel lift boots, were not consistently implemented. Certified Nursing Assistants (CNAs) were unaware of the care plan requirements for turning and repositioning, and there was no documentation to show that these interventions were carried out. During observation, the resident was found with only one heel boot in place, and a deep tissue injury with eschar was discovered on the left heel. The nurse confirmed that the wound had worsened without proper documentation or notification. Interviews with nursing staff and the Director of Nursing revealed that documentation of turning and repositioning was not routinely performed, and changes in wound condition were not always promptly recorded or communicated to the physician. Facility policies required documentation of services provided, changes in condition, and timely notification of the physician, but these were not followed. The lack of adherence to care plans, incomplete documentation, and failure to implement preventative measures led to the development and worsening of pressure ulcers in both residents.
Failure to Document and Honor Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that residents' rights regarding treatment choices and advance directives were known and protected for seven residents. For three residents with cognitive impairments or serious illnesses, there was no documented evidence that an advance directive was requested or discussed, as required in Section D of their POLST forms. The Social Services Director (SSD) was unaware of her responsibility to inquire about advance directives, and the Director of Nursing (DON) confirmed that social services should be responsible for obtaining this information and ensuring it is documented. Facility policy also required that residents' choices regarding treatment be incorporated into their care plans, but this was not consistently done. In two cases, there were discrepancies between the code status documented in the electronic medical record (EMR) and the code status listed on the POLST forms. One resident's POLST indicated Do Not Resuscitate (DNR), while the EMR listed them as Full Code, and another resident's POLST and EMR had conflicting code statuses. Staff interviews revealed that the process for determining code status was inconsistent, with some staff checking both the POLST and the EMR, but not always ensuring they matched. This led to an incident where a resident received CPR despite having a DNR order on the POLST. Additionally, for a resident with a Power of Attorney (POA) in place, the facility discussed advance directives with the resident rather than the legally recognized representative, despite the resident lacking decision-making capacity. Another resident's POLST form was incomplete, with Section D left blank, and the SSD confirmed this omission. Facility policies reviewed indicated the importance of documenting and honoring residents' treatment wishes, but these procedures were not consistently followed, resulting in failures to respect residents' rights and preferences regarding emergency treatment.
Failure to Develop and Implement Care Plans for Infection Control and Advance Directives
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, resulting in deficiencies related to infection control and honoring advance directives. Two residents, who were roommates, were admitted with active multi-drug resistant organism (MDRO) infections, specifically Escherichia coli producing Extended Spectrum Beta Lactamase. Although both residents were placed on Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact care and identification with an orange dot, their care plans did not initially include specific interventions or goals related to MDRO management. The Infection Preventionist confirmed that the EBP care plans for these residents were not developed until after the precautions were already in place, which meant staff may not have been fully informed or consistent in following the necessary infection control measures. Additionally, a third resident with a diagnosis of atrial fibrillation had a Physician Orders for Life Sustaining Treatment (POLST) indicating Do Not Resuscitate (DNR) status, which was signed by the responsible party and a physician's assistant. Despite this, the resident's care plan, which documented the DNR status and the goal to have her wishes followed, was not implemented. As a result, staff initiated full cardiopulmonary resuscitation (CPR) on the resident against her documented wishes. Facility policies required that comprehensive, person-centered care plans be developed and implemented for each resident, including measurable objectives and timeframes to meet their needs. The failure to create and implement these care plans as required led to lapses in infection control for the two residents with MDROs and a failure to honor the advance directive for the resident with DNR status.
Failure to Provide Prescribed Fortified and Finger Food Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual dietary needs of several residents during a lunch meal. Specifically, three residents who were prescribed a fortified diet to increase caloric intake were served regular mashed potatoes instead of the required fortified mashed potatoes. The fortified mashed potatoes, as described by the Dietary Manager, should have included extra butter and half and half for additional calories, but these were not provided. The Dietary Manager acknowledged the importance of following ordered diets to prevent unintended weight loss or worsening medical conditions, but could not locate a fortified diet policy. Additionally, a resident who was ordered a finger food diet received a regular meal tray that included items not suitable for finger feeding, such as an open-faced pork sandwich with gravy, mashed potatoes, and glazed carrots. The Registered Dietician confirmed that the resident's meal card indicated a finger food diet and that the facility's policy for finger foods was not followed, despite appropriate finger foods being available in the kitchen. The facility's policy specified that finger foods should be easy to pick up and eat, and that foods like mashed potatoes and sauced vegetables should be avoided for residents on this diet.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to ensure safe food storage, preparation, and maintenance of kitchen equipment and food contact surfaces in accordance with professional standards for food safety for all 89 residents receiving facility-prepared meals. Surveyors observed that the stove, oven, convection oven, backsplash, and sides of the oven contained grease, food particles, and encrusted grime. The Dietary Manager (DM) and Registered Dietician (RD) both confirmed that these areas should be cleaned after each use and at least weekly, and that the lack of cleanliness did not meet expectations. The RD emphasized that unclean equipment and surfaces could lead to bacterial growth and cross-contamination. During the kitchen tour, it was found that sliced yellow cheese had been removed from its original packaging and stored in an unlabeled, undated container in the refrigerator. Additionally, containers of pumpkin and cranberry sauce were available for use beyond their use-by dates. The DM and RD both stated that this practice was unacceptable and increased the risk of illness from expired or contaminated foods. Other unsanitary conditions included a floor sink with rust-colored stains, chipped paint, debris, and liquid splatter, as well as a damaged wall behind a food preparation table with chipped paint, exposed drywall, and dried food particles. Clean metal sheet pans were found with food particles and grease, and the steam table had encrusted food residue and stains. Further observations revealed that an industrial meat slicer and mixer, both wrapped in dirty clear plastic and considered clean, were actually stained and splattered with food particles. A baked cake was not properly sealed and was stored on a shelf with dried food particles, and another cake was prepared in a pan with encrusted residue and rust, then served to residents. The DM and RD confirmed that these practices did not meet expectations and posed risks of contamination. Facility policies and FDA Food Code requirements reviewed by surveyors indicated that equipment and food contact surfaces must be clean, food must be labeled and dated, and all food must be properly covered and stored to prevent cross-contamination.
Infection Control Lapses in PPE Use, EBP Implementation, and Equipment Disinfection
Penalty
Summary
The facility failed to maintain its infection prevention and control program for its residents, as evidenced by multiple observed lapses in infection control practices. A physical therapy assistant was observed entering the room of a COVID-19 positive resident while wearing only a surgical mask, rather than the required N95 respirator. The infection preventionist confirmed that facility policy required staff to wear an N95 respirator, gown, gloves, and face shield when entering rooms of COVID-19 positive residents, and that a surgical mask would not provide sufficient protection. Additionally, a certified nurse assistant was observed transferring a resident who was on enhanced barrier precautions (EBP) due to an indwelling urinary catheter, without wearing a gown. The CNA acknowledged the omission and the infection preventionist explained that gowns are necessary to prevent the spread of multidrug-resistant organisms (MDROs). Furthermore, two residents with documented MDRO infections were not placed on EBP, and there was no signage or PPE on their doors until the infection preventionist intervened. Facility policy indicated that EBP should be initiated for residents known to be colonized or infected with MDROs or who have indwelling medical devices. During a medication pass, a licensed nurse was observed cleaning a glucometer with a bleach wipe but did not allow the required four-minute wet contact time for effective disinfection, instead wrapping the device in a paper towel immediately after wiping. The nurse was unaware of the required dwell time, and the infection preventionist confirmed that improper sanitization could expose residents to bacteria and bloodborne pathogens. Facility policy and the bleach wipe manufacturer’s instructions both specified the need for a four-minute wet contact time between uses on different residents.
Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of three residents by not ensuring their call lights were within reach. In one instance, a resident with limited mobility was observed trying to find the call light, which was found under the pillows and not accessible. The licensed nurse confirmed the call light was not in reach and acknowledged the resident would not have been able to locate it independently. The resident's care plan indicated a history of attempting to get out of bed independently and emphasized the importance of timely call light response and reminders to use the call light for assistance. In another case, a resident's call light was attached to the bottom of the bed rail, a few inches from the floor, making it inaccessible while the resident was in bed. Both a CNA and an LVN confirmed the call light was out of reach and stated that residents should always have access to their call lights. In a third instance, a resident's call light was found on a chair, not within reach, and the licensed nurse present confirmed it should have been accessible. The facility's policy required call devices to be placed within the resident's reach before staff left the room.
Failure to Honor DNR Status Due to Inconsistent Documentation
Penalty
Summary
A deficiency occurred when a resident with diagnoses including atrial fibrillation and dementia did not receive care in accordance with their Physician Orders for Life-Sustaining Treatment (POLST). The resident's POLST, signed by the responsible party and a physician's assistant, indicated a Do Not Resuscitate (DNR) status. However, the resident's electronic health record (EHR) and physician's orders still reflected a full code status, which led to confusion among staff regarding the resident's resuscitation wishes. When the resident was found unresponsive, staff checked the EHR, which indicated full code, and initiated CPR, including chest compressions, use of a backboard, bag-valve mask, and administration of epinephrine. Emergency Medical Services (EMS) arrived and continued resuscitation efforts. It was only after these interventions that staff discovered the resident's POLST indicated DNR, but by then, life-saving measures had already been performed for several minutes. Interviews with nursing staff revealed inconsistent processes for verifying code status, with some staff relying solely on the EHR and others referencing the POLST. The facility's policies required honoring advanced directives and POLST forms, but the failure to update the EHR to reflect the resident's current DNR status resulted in the resident receiving CPR against their documented wishes.
Failure to Ensure Resident Hydration Due to Inaccessible Fluids
Penalty
Summary
A deficiency occurred when a resident was not provided with adequate hydration according to facility policy and the resident's care plan. During an observation and interview, the resident expressed thirst and was unable to find any fluids within reach on her bedside table. Both a licensed nurse and a certified nursing assistant confirmed that the resident's water was not accessible and acknowledged the risk of dehydration. The resident was observed to have dry, cracked, and peeling lips, which are signs of dehydration. The certified nursing assistant also confirmed these symptoms during the observation. The resident's care plan, revised previously, specified that the resident should not exhibit signs or symptoms of dehydration and that nursing staff should cue the resident to take frequent sips of fluid. The facility's hydration policy required that water be available at the bedside for residents not on fluid restrictions and that staff observe for signs of dehydration, including dry, cracked lips. The director of nursing confirmed that fluids should always be within reach, especially for residents showing signs of dehydration.
Failure to Provide Physician-Ordered Oxygen Therapy and Required Signage
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for two residents. For one resident with a diagnosis of chronic obstructive pulmonary disease (COPD), oxygen therapy was administered via nasal cannula at a flow rate of 1.5 liters per minute without a current physician order. The resident confirmed ongoing oxygen use since admission, and a licensed nurse acknowledged the absence of a physician order, stating this could result in the resident receiving an incorrect dosage. Additionally, there was no 'oxygen in use' sign posted outside this resident's room, which was confirmed by both the nurse and the Director of Nursing (DON) as a deviation from facility expectations. For another resident receiving oxygen therapy, there was also no 'oxygen in use' sign posted outside the room. A certified nurse assistant and a licensed nurse confirmed the absence of the sign, with the DON stating that facility policy requires such signage to alert staff and others to the presence of oxygen due to its flammability. The facility's policy on respiratory care and oxygen administration specifies that oxygen is to be administered per physician order and that appropriate signage must be posted in accordance with regulations. These observations and interviews demonstrate that the facility did not follow its own policy or professional standards in these instances.
Failure to Timely Administer Pain Patch as Ordered
Penalty
Summary
A deficiency occurred when a licensed nurse failed to apply a Lidocaine patch for pain management to a resident as ordered by the physician. The nurse signed off in the medical record that the patch had been applied at the scheduled time, but in reality, the patch was not placed until three hours later. During this period, the resident, who had a history of malignant neoplasm and rheumatoid arthritis, reported being in pain and was observed without the prescribed patch in place. The nurse acknowledged the delay and the importance of timely application for effective pain control. The resident's care plan included interventions for chronic pain related to knee pain and scoliosis, with goals for satisfactory pain control and administration of pain medications as ordered. Facility policy required residents to receive pain management according to physician orders and documentation of pain levels. The failure to apply the Lidocaine patch as scheduled resulted in the resident experiencing unrelieved pain, as confirmed by both the resident and staff interviews, as well as direct observation.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure proper administration of medications for two residents. For one resident with a history of malignant neoplasm and rheumatoid arthritis, a nurse left a PRN acetaminophen tablet at the bedside without observing the resident take it. The resident later showed that the medication had not been ingested, and the nurse confirmed she did not watch the resident take the medication. Facility policy requires that medications be administered as prescribed and that the person administering the medication observe the resident to ensure ingestion. For another resident with gastro-esophageal reflux disease and a history of gastrointestinal bleeding, a nurse administered Sucralfate during the resident's meal instead of before the meal as prescribed. The nurse acknowledged the medication was due before the meal and was administered late. Facility policy states that medications should be given within a specific time frame and in accordance with physician orders, including timing related to meals.
Improper Disposal of Garbage Due to Open Dumpster Lid
Penalty
Summary
A deficiency was identified when a garbage dumpster bin located outside behind the building was observed with its lid propped open during a concurrent observation and interview with the Dietary Manager (DM). The DM confirmed that the lid was open and acknowledged that it should be kept closed and secured to prevent attracting rodents. In a subsequent interview, the Registered Dietician (RD) also stated that the expectation was for the dumpster bin to be closed and noted the risk of attracting rodents if left open. A review of the 2022 Food Code indicated that outside receptacles must have tight-fitting lids or covers to prevent the entry of rodents and the breeding of flies. This failure had the potential to lead to insect and rodent infestation for the 89 residents living at the facility.
Incomplete Medical Records and Inadequate Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, laboratory results belonging to another individual were found in their medical record. This error was confirmed by the Director of Nursing (DON), who acknowledged that the incorrect laboratory results were placed in the resident's file by accident, which could have led to the wrong results being reported to the physician. For another resident, the facility did not ensure that psychotropic medication informed consent documents included the required details of frequency, dose, and duration for multiple medications, including trazodone, abilify, and divalproex sodium. The DON confirmed that the consent forms were incomplete and that no progress notes were made in accordance with the facility's policy and procedure for informed consent for psychotropic drugs. The policy required documentation of the drug, dose, frequency, rationale, risks, and the individuals involved in the consent process, none of which were fully documented in this case.
Failure to Offer Pneumococcal Booster Vaccine to Eligible Resident
Penalty
Summary
The facility failed to ensure that one of twenty-five sampled residents was offered the pneumococcal booster vaccine (PPSV23) despite being eligible. The resident in question had a medical history that included muscle weakness, anemia, Type 2 Diabetes Mellitus, and chronic obstructive pulmonary disease. The resident's immunization record showed receipt of the PCV13 vaccine, but there was no documentation that the PPSV23 vaccine was offered or administered as recommended for adults over 65 years old with certain chronic conditions. During interviews and record reviews, both the Infection Preventionist and the Director of Nursing confirmed that the resident was eligible for the PPSV23 vaccine and acknowledged that it should have been offered. The CDC guidelines reviewed by the facility staff indicated that adults 65 years or older, especially those with chronic lung conditions, should receive the PPSV23 vaccine even if they had previously received the PCV13 vaccine. The failure to offer the vaccine was identified through review of the resident's records and staff interviews.
Failure to Maintain Kitchen Equipment and Ensure Safe Environment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically a steamer that was observed leaking water onto the floor during multiple observations. The leak caused water to collect on a maroon kitchen tray, which then overflowed onto the ground, creating a wet floor. Staff confirmed that the tray needed to be emptied repeatedly to prevent overflow, and that the steamer had been repaired several times but continued to leak. No wet floor caution signs were present in the area during these observations. The Dietary Manager acknowledged that the leaking steamer could harbor bacteria or create a fall hazard and confirmed that the equipment required further repair and that the floor should remain dry. Review of the facility's policy indicated that all equipment should be routinely cleaned and maintained according to manufacturer’s directions, and that maintenance requests should be submitted as needed.
CNA Provides Resident with THC Vape Pen
Penalty
Summary
The facility failed to ensure a resident remained free from accidents and hazards when a Certified Nursing Assistant (CNA) provided the resident with a vape pen containing tetrahydrocannabinol (THC). This incident involved a resident with a history of anxiety and chronic obstructive pulmonary disease (COPD), who was on supplemental oxygen. The resident, who did not use marijuana or vape products according to their smoking assessment, informed staff that they had used the vape pen given by the CNA, which could have been laced with an unknown substance. Interviews with staff revealed that the CNA was not supposed to share personal vape pens with residents, as it could lead to potential health risks such as lung injury or confusion. The facility's policy prohibited staff from providing smoking items to residents, and the use of electronic cigarettes was considered a risk due to potential health effects. The CNA admitted to giving the resident the vape pen after the resident expressed feelings of anxiety and a desire for marijuana or alcohol. The facility's Administrator and Director of Nursing acknowledged that the facility's policies were not followed. The Drug-Free Workplace Policy, which the CNA had signed, prohibited the possession or use of illegal drugs, including marijuana, on company property. The Physician Assistant was informed after the incident and instructed staff to remove the vape pen from the facility and monitor the resident for adverse effects. The facility's failure to adhere to its policies and procedures resulted in a deficiency related to accident hazards and supervision.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of care plan interventions for a resident, leading to a fall and subsequent injuries. The resident, who had a history of falls and was at high risk due to conditions such as Parkinson's disease and muscle weakness, was not provided with the necessary fall mat and two-person assistance during activities of daily living. On the day of the incident, a CNA was changing the resident's brief without the required assistance, resulting in the resident falling from the bed and sustaining multiple injuries, including a broken clavicle. The resident's care plan, which included interventions like fall mats and two-person assistance, was not followed. The CNA involved was unaware of the care plan requirements and did not know where to find this information in the resident's records. This lack of knowledge and adherence to the care plan contributed to the resident's fall and subsequent decline in physical abilities, including the loss of independence in feeding herself. Interviews with staff, including the DON and the MDS Nurse, confirmed that the care plan was not followed, and the necessary precautions were not in place. The facility's policies and procedures, which required staff to review and follow care plans, were not adhered to, leading to the resident's injuries and increased dependency on staff for daily activities.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Andreas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kit Carson Nursing & Rehabilitation Center | 12.5 mi | ★★★★★ | 23 | 0 |
| Adventist Health Sonora - D/p Snf | 21.1 mi | ★★★★★ | 1 | 0 |
| Golden Sonora Care Center | 21.8 mi | ★★★★★ | 8 | 0 |
| Oakdale Nursing And Rehabilitation Center | 31.6 mi | ★★★★★ | 0 | 0 |
| Lodi Creek Post Acute | 33.3 mi | ★★★★★ | 24 | 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 October 2026) and official state health department websites.