Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Granite Hills Healthcare & Wellness Centre, Llc during CMS and state inspections, most recent first.
A resident with left-sided hemiplegia and dementia had a fall risk care plan that included general fall precautions but did not address the need to keep personal items on the unaffected side for safe access. On one occasion, a CNA left for a lunch break without notifying the covering CNA, and the resident’s bedside table was positioned on the affected side, making items difficult to reach. After the roommate activated the call light, staff found the resident on the floor between beds with a forehead injury and later learned the resident had fallen while reaching for the remote on the bedside table. Hospital evaluation revealed a sutured forehead laceration and a femoral neck fracture.
A resident with dementia was involved in an altercation with a roommate, resulting in a bruise under the eye. The facility failed to report the injury within 24 hours, delaying the abuse investigation. The resident's family reported the injury, and staff speculated it might have occurred during an attempt to open a gate. The DON acknowledged the failure to report the incident to authorities as required by policy.
The facility failed to maintain safe food practices, with peeling paint in the kitchen ceiling posing a contamination risk, and staff entering the kitchen without proper hair coverings. The issues were reported but not addressed, and staff admitted to knowing the requirements for hair restraints.
The facility failed to maintain a homelike environment in four rooms within a secured unit. Observations revealed issues such as calcified sinks, broken furniture, exposed wires, and mold, which were acknowledged by the Director of Maintenance and the DON as not meeting the facility's policy for a clean and comfortable environment.
The facility failed to maintain a safe environment in six resident rooms, with hazards such as protruding wires and loose toilet seats. Additionally, a resident with a history of weakness was transferred using a mechanical lift by a single CNA, contrary to the facility's policy requiring two-person assistance. These deficiencies posed a risk of injury to residents.
The facility's QAPI plan failed to identify deficient practices, including the lack of staff education on managing residents with PTSD and unaddressed environmental hazards. During interviews, the DON confirmed no PTSD-related education was provided, and the ADM admitted to being unaware of the environmental hazards and the existence of a safety committee.
A resident with Parkinson's disease and cataracts was inaccurately assessed in the MDS as having adequate vision, despite expressing blindness and difficulty seeing. The MDS Nurse admitted the error, which led to CMS being uninformed of the resident's impaired vision. The DON expected accurate MDS assessments, but the facility failed to follow the MDS Resident Assessment Instrument guidelines.
A resident with Parkinson's disease and cataracts experienced weight loss due to unaddressed visual impairment, as the facility failed to follow through on a referral to an ophthalmologist. Despite the resident's repeated complaints about his inability to see, there was no documented evidence of a consultation with an eye specialist, and the facility's policy on referrals was not effectively implemented.
A resident with Parkinson's and impaired vision experienced significant weight loss due to the facility's failure to investigate the root cause of his nutritional issues. Despite the resident's complaints about his inability to see food, the facility did not explore his vision problems or implement effective interventions. The resident's food consumption was inaccurately documented, and the care plan was not properly executed, leading to further weight loss.
The facility failed to identify and address PTSD triggers for two residents, leading to a deficiency in trauma-informed care. One resident, with PTSD and other mental health diagnoses, reported staff were unaware of his triggers, which were not documented in his care plan. Another resident, with PTSD from past abuse, experienced physical symptoms when triggered, but staff were unaware of her condition. The facility's policy requires identifying and mitigating triggers, but this was not implemented, potentially causing psychosocial harm.
A facility failed to monitor a resident's behaviors and side effects of a psychotropic medication prescribed for Tourette's Disorder and dementia. The resident exhibited self-harm behavior, and there was no evidence of behavior tracking or side effect monitoring in the MAR. Interviews with staff highlighted the importance of such monitoring, but the facility's policy was not adhered to, placing the resident at risk.
A facility failed to secure treatment and medication carts in the East Station area, leaving them unlocked and unattended. The treatment cart contained prescription creams, ointments, scissors, and wound dressing materials, while the medication cart held over-the-counter and prescription medications. LN 1 admitted to forgetting to lock the medication cart, and both the DSD and DON confirmed that carts should be locked when not in use to prevent unauthorized access.
The facility failed to accurately document food intake for a resident with Parkinson's disease, leading to discrepancies in monitoring weight loss. Additionally, care documentation for a resident with cerebral infarction was inaccurate due to a CNA using another's login credentials, highlighting issues with password sharing and record accuracy.
A facility failed to create a person-centered care plan for a resident with cognitive impairment and combative behavior during ADLs. Despite staff observations and interviews indicating the resident's tendency to hit during care and his responsiveness to Spanish, no care plan was developed to manage these behaviors, contrary to the facility's policy.
The facility failed to implement its fall prevention program for two residents with a history of falls. One resident had unwitnessed falls and lacked a functioning call light, while another had falls with an inaccessible call light and closed bedroom door. Staff were unaware of the fall risks, and no IDT meetings or care plan revisions were conducted as required by the facility's policy.
A resident's representative experienced a delay in receiving requested medical records due to the facility's failure to follow its policy of providing records within two working days. The Medical Record Department did not maintain a log of requests and delayed the process by not promptly seeking corporate approval. The Director of Nursing acknowledged the lapse in following the established procedure.
A facility failed to follow discharge protocols for a resident with End Stage Renal Disease. Despite a bed hold agreement, the resident was discharged without a 30-day notice or appeal information. The DON cited unmet needs and non-compliance as reasons for discharge, but the resident was ready for discharge from the hospital before the bed hold expired. The resident was distressed about not returning to his home and retrieving belongings.
A resident with cirrhosis and hepatic encephalopathy did not receive lactulose as prescribed, as the MAR lacked documentation of administration on specific dates. Interviews confirmed the absence of required initials, indicating potential non-administration, which could impact the resident's health.
A facility failed to implement an individualized care plan for a resident with paranoid schizophrenia and bipolar disorder, leading to a risk of elopement. The resident was observed unattended on the patio and had previously eloped by climbing over a fence. Despite a physician's order for a wanderguard, the system was not functional, and the resident was only monitored one-on-one during the PM/NOC shift. The facility's policy required immediate interventions, but the care plan did not adequately address the risk, as acknowledged by the DON.
The facility failed to ensure cooks followed recipes, impacting residents' nutritional status and satisfaction. Residents complained about the food quality, describing it as bad and insufficient. Observations showed improper chicken preparation and inadequate portion sizes for deli meat sandwiches, with the food service director acknowledging these issues.
A resident with a history of suicidal behavior swallowed a metal fork after being left unattended during mealtime, despite a care plan requiring close supervision. The resident had previously been observed breaking utensils and required one-to-one assistance during meals. The CNA left the resident alone briefly, leading to the incident, and the facility lacked a policy on mealtime supervision.
A resident with End Stage Renal Failure had a blood draw from his fistula, contrary to his care plan. The procedure was not documented in the medical record, and the phlebotomist did not indicate the blood draw location. The ADON confirmed that proper documentation was not followed.
Failure to Individualize Fall Prevention for Hemiplegic Resident Leading to Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and individualized care planning for a resident with left-sided hemiplegia and hemiparesis. The resident’s care plan, dated 12/8/2025, identified a risk for falls related to impaired mobility and a history of CVA and included interventions such as nonskid socks, clutter-free environment, adequate lighting, low bed, call light within reach, and reorientation as needed due to dementia. However, the care plan did not address the resident’s specific physical limitation by directing staff to place personal items and belongings on the resident’s right (unaffected) side for safe and easy access. The facility’s fall management policy stated that the facility would maintain an environment free of accident hazards and provide adequate supervision and assistive devices to prevent avoidable accidents. On the day of the incident, the resident’s roommate activated the call light, and staff later found the resident on the floor between the B-bed and C-bed in a three-bed room. The bedside table was observed tilted and pushed against the B-bed, and the resident had a bump and superficial scrape on the right forehead with a moderate amount of blood. The resident reported reaching for the remote control on the bedside table, feeling weak, and then falling to the floor. The DON stated that the facility’s investigation determined the bedside table had been placed on the resident’s affected side, making it difficult for the resident to reach needed items. CNA 1 acknowledged knowing the resident had left-sided weakness and that the bedside table should have been on the right side, but could not recall the table’s position before leaving for a 30‑minute lunch break and did not inform the covering CNA of her absence. The resident was transferred to the hospital, where a superficial forehead laceration was sutured and a femoral neck fracture was diagnosed.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within 24 hours for a resident, which delayed the abuse investigation and placed residents at risk for abuse. The resident, who was admitted with diagnoses including muscle weakness and dementia, was involved in an altercation with a roommate. A licensed nurse observed the altercation but was unsure if there was physical contact. Later, a certified nursing assistant noticed a dark purple bruise under the resident's left eye, which was believed to have been caused by the altercation, although the incident was not witnessed. The Assistant Director of Nursing was informed by the resident's family about the bruise and a cut on the resident's arm, and it was suggested that the injuries might have occurred when the resident attempted to open a gate. The Director of Nursing was also informed by the family that the resident claimed to have been punched. Despite these reports, the injury was not reported to the state licensing agency, and the Director of Nursing acknowledged that the incident should have been reported immediately to the appropriate authorities. The facility's policy requires that unexplained injuries be promptly investigated and reported, which was not adhered to in this case.
Failure to Maintain Safe Food Practices
Penalty
Summary
The facility failed to adhere to safe food practices, as evidenced by two main issues. Firstly, the ceiling above the kitchen tray line area was observed to have peeling and bubbling paint, with pieces hanging downwards, which posed a risk of contamination to resident food and kitchen equipment. The Certified Dietary Manager (CDM) had reported the issue multiple times to the maintenance department, but the repairs were never completed. The Director of Maintenance, who started working at the facility in July 2024, was unaware of the ceiling issues until the day of the survey. The Registered Dietician (RD) and the Director of Nursing (DON) both acknowledged the importance of repairing the ceiling to prevent contamination. Secondly, two staff members were observed entering the kitchen without proper hair coverings. Kitchen Aide 1 (KA 1) and Dishwasher 1 (DW) both entered the kitchen wearing baseball hats without hair nets, and DW also had an uncovered beard. Both staff members admitted to knowing the requirement for hair and beard coverings to prevent cross-contamination. The CDM confirmed that sanitation and hairnet training had been provided to the staff, and the RD and DON emphasized the necessity of hair restraints to prevent contamination of food and equipment.
Failure to Maintain Homelike Environment in Secured Unit
Penalty
Summary
The facility failed to provide a homelike environment for residents in four rooms within a secured unit, as observed during a survey. In one room, the sink was centrally located and covered with lime green calcification, which the Director of Maintenance (DM) acknowledged as unsanitary and in need of replacement. Another room had broken plastic cord covers, missing dresser knobs, and a leaning dresser, making it difficult for residents to use their furniture. The DM confirmed these issues and noted the room did not appear neat or homelike. In a third room, both beds lacked dresser knobs, a cable wire was protruding from the wall, and the thermostat was exposed, which the DM described as non-functional and unappealing. In the fourth room, a resident expressed dissatisfaction with mold around the sink, which she believed was affecting her health. The DM noted the poor condition of the sink area and agreed it was not homelike. The Director of Nursing (DON) also acknowledged that missing dresser handles did not contribute to a homelike environment. The facility's policy emphasizes providing a clean, comfortable, and homelike environment, which was not upheld in these instances.
Environmental Hazards and Inadequate Supervision in Resident Transfers
Penalty
Summary
The facility failed to maintain a safe environment for residents in six of the fifteen rooms reviewed for accidents. Observations revealed various hazards, including a protruding cable wire, splintered plastic cord covers, a hole in a bathroom door, a protruding screw head on a dresser, a loose toilet seat, peeling paint, and a long cable cord. These hazards were identified during observations and interviews with the Director of Maintenance (DM), who admitted to being unaware of these issues and acknowledged their potential to cause harm to residents. The facility's policy required immediate notification of unsafe situations, but these hazards were not addressed promptly. Additionally, the facility failed to provide adequate assistance during the transfer of a resident using a mechanical lifting device. Resident 29, who had a history of complete and partial weakness following a stroke, was transferred by a single Certified Nursing Assistant (CNA) instead of the required two-person assistance. The CNA admitted to performing the transfer alone due to the unavailability of other staff, despite having received training on the necessity of two-person assistance for safety. Interviews with other CNAs and the Director of Staff Development confirmed that the facility's policy required two-person assistance for mechanical lifts, although this was not explicitly stated in the policy. The facility's failure to address environmental hazards and provide adequate supervision during resident transfers posed a risk of injury to residents. The Director of Nursing (DON) acknowledged the expectation for resident rooms to be safe and free of hazards and confirmed the requirement for two-person assistance during mechanical lifts. Despite these expectations, the facility's policies and practices did not ensure compliance, leading to potential harm to residents.
QAPI Plan Fails to Address PTSD Education and Environmental Hazards
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) plan, developed by the Quality Assessment and Assurance (QAA) committee, failed to identify deficient practices prior to their recertification survey. Specifically, the facility did not provide education to staff regarding the management of residents with post-traumatic stress disorder (PTSD) and the associated triggers. Additionally, the facility did not identify and correct environmental hazards that could have caused injury. During a joint interview with the Administrator (ADM) and the Director of Nursing (DON), it was revealed that no education was provided to staff about PTSD, and the ADM acknowledged awareness of maintenance issues but had not identified the environmental hazards found during the survey. The ADM was also unaware of the existence of a safety committee within the facility.
Inaccurate Vision Assessment and MDS Reporting
Penalty
Summary
The facility failed to accurately assess, document, and transmit Minimum Data Set (MDS) information regarding a vision assessment for a resident with impaired vision. The resident, who was readmitted with diagnoses including Parkinson's disease, expressed difficulty seeing and stated he was blind. Despite this, the most recent quarterly MDS inaccurately listed the resident's vision as adequate. The care plan indicated impaired vision related to cataracts, and an eye doctor consultation confirmed bilateral cataracts. However, there was no documentation of a follow-up ophthalmology appointment. The MDS Nurse acknowledged the inaccuracy in the vision assessment, stating that the incorrect coding led to CMS being unaware of the resident's impaired vision. The Director of Nursing expected MDS assessments to be accurate to provide CMS with a clear picture of each resident's status. The MDS Resident Assessment Instrument outlines steps for assessing vision, which include consulting direct care staff and the resident about visual abilities, but these steps were not effectively followed, resulting in the deficiency.
Failure to Address Resident's Visual Impairment
Penalty
Summary
The facility failed to address a resident's visual impairment in a timely manner, leading to a deficiency in quality of care. Resident 3, who was readmitted with Parkinson's disease and cataracts, experienced weight loss due to his inability to see his food. Despite a care plan intervention to arrange a consultation with an eye practitioner, there was no documented evidence that Resident 3 was referred to or seen by an ophthalmologist. Observations and interviews revealed that Resident 3 repeatedly expressed his inability to see, which was not adequately addressed by the staff. The facility's records showed that Resident 3 had cataracts diagnosed in both eyes, and a referral to an ophthalmologist was noted but not followed through. The Social Services Director confirmed the lack of follow-up, and the Director of Nursing acknowledged that the resident's vision care was not addressed in a timely manner. The facility's policy on referrals to outside services was not effectively implemented, as there was no specific policy for vision care, contributing to the oversight in addressing Resident 3's needs.
Failure to Address Resident's Vision and Nutrition Needs
Penalty
Summary
The facility failed to investigate and analyze the root cause of weight loss for a resident diagnosed with Parkinson's disease and impaired vision due to cataracts. The resident was observed with untouched meal trays and expressed difficulty in eating because of his inability to see the food. Despite the resident's complaints about his vision, the facility did not explore or investigate the issue during the Interdisciplinary Team (IDT) meeting, nor was there any documented evidence of a recent vision exam. The resident's weight had decreased from 170.5 pounds to 156.5 pounds over six months, indicating a 13.7% weight loss. The facility's records inaccurately documented the resident's food consumption, showing 75-100% intake when observations indicated no food was consumed. The care plan included interventions such as providing finger foods and nutritional supplements like Ensure, but these were not effectively implemented, as evidenced by the non-finger food items on the resident's breakfast tray. The Registered Dietician (RD) acknowledged the oversight in addressing the resident's vision issues and the lack of discussion on using soda as an incentive for eating. The Director of Nursing (DON) expected the IDT to collaborate and address the root cause of the resident's weight loss, which included the unaddressed visual impairment. The facility's policy on evaluating nutritional status emphasized assessing and analyzing factors affecting residents' nutritional needs, which was not adequately followed in this case.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify and address triggers related to PTSD for two residents, leading to a deficiency in providing trauma-informed care. Resident 27, who was admitted with diagnoses including PTSD, anxiety disorder, and schizoaffective disorder, expressed that staff were not aware of how to handle his PTSD. Interviews with staff, including a licensed nurse and the Assistant Director of Nursing, revealed a lack of awareness and documentation of Resident 27's PTSD triggers in his care plan. The Social Service Director noted that Resident 27 did not like people behind him or screaming, but these triggers were not documented or addressed in his care plan. Similarly, Resident 35, who was readmitted with a PTSD diagnosis, reported that her PTSD stemmed from past abuse and that she experienced physical symptoms when triggered. Interviews with a CNA and a licensed nurse indicated that they were unaware of Resident 35's PTSD diagnosis and triggers. The Director of Nursing emphasized the importance of knowing a resident's PTSD diagnosis and triggers to prevent re-traumatization and manage emotional needs, but this was not reflected in Resident 35's care plan. The facility's policy on trauma-informed care requires the identification and mitigation of triggers to prevent re-traumatization. However, the failure to implement this policy for Residents 27 and 35 resulted in a deficiency, as staff were not informed or trained to handle the residents' PTSD triggers, potentially leading to severe psychosocial harm and affecting their quality of life.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to monitor the behaviors and side effects of a psychotropic medication for a resident diagnosed with Tourette's Disorder and dementia. The resident, who had a BIMS score indicating cognitive impairment, was observed with an open wound between the upper lip and nose, which was attributed to self-harm behavior related to Tourette's Disorder. The resident was prescribed risperidone to manage symptoms such as tics and skin picking, but there was no evidence in the Medication Administration Record (MAR) that these behaviors were being tracked or that the resident was being monitored for side effects of the medication. Interviews with the Licensed Nurse and the Director of Nursing revealed that the facility recognized the importance of monitoring the resident's behaviors and potential side effects of the psychotropic medication to assess its effectiveness and ensure the resident's safety. However, the facility's policy on Behavior/Psychoactive Drug Management, which required specific behavior monitoring and side effect observation, was not followed. This oversight placed the resident at risk for receiving unnecessary medication and experiencing unrecognized adverse reactions.
Failure to Secure Treatment and Medication Carts
Penalty
Summary
The facility failed to secure one of three treatment carts and one of three medication carts in the East Station area, as observed during a survey. On the morning of January 30, 2025, a treatment cart was found unlocked and unattended near the nurse's station, containing prescription creams, ointments, scissors, and wound dressing materials. Similarly, a medication cart was also found unlocked and unattended, containing over-the-counter and prescription medications. No staff were present in the area at the time of these observations. Licensed Nurse 1 (LN 1) admitted to forgetting to lock the medication cart, acknowledging that this oversight could allow residents, staff, and visitors unauthorized access to medications, potentially causing harm. The Director of Staff Development (DSD) and the Director of Nursing (DON) both confirmed that treatment and medication carts should be locked when not in use to prevent unauthorized access and potential harm. The facility's policy, dated April 2008, specifies that only licensed nurses, pharmacy personnel, and those lawfully authorized should have access to medications.
Inaccurate Documentation of Resident Care and Food Intake
Penalty
Summary
The facility failed to accurately document food intake percentages for a resident with Parkinson's disease, who was experiencing weight loss. Observations revealed that the resident did not consume his meals, yet the documentation inaccurately recorded a 75-100% consumption for both breakfast and lunch. The Registered Dietician (RD) expressed reliance on accurate documentation to monitor residents' nutritional intake, especially for those with weight loss. The Director of Nursing (DON) emphasized the importance of precise documentation to prevent further weight loss, aligning with the facility's policy on recording food intake. Additionally, the facility failed to accurately document care provided to a resident with cerebral infarction and functional quadriplegia. The resident's chart inaccurately indicated a shower was given, while a Certified Nursing Assistant (CNA) reported providing a bed bath. The CNA used another staff member's login credentials to document the care, which was against the facility's policy. The Director of Staff Development (DSD) and the DON both highlighted the importance of accurate documentation and the risks associated with password sharing, which could lead to inaccurate records.
Failure to Develop Person-Centered Care Plan for Combative Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for Resident 84, who was admitted with diagnoses including cerebral infarction and anxiety disorder. The resident was cognitively impaired, as indicated by a BIMS score of 3. Observations and interviews with CNAs revealed that Resident 84 exhibited combative behavior during ADLs, such as attempting to hit staff during shaving and nail care. Despite these behaviors, there was no care plan in place to address or manage these combative tendencies. Interviews with staff, including CNAs and a Licensed Nurse, highlighted that Resident 84 was confused but responded to Spanish, which could be used to calm him during care. The Director of Nursing acknowledged the importance of having an individualized care plan for Resident 84, especially given his confusion, combative behavior, and language needs. However, a review of the resident's records confirmed the absence of such a care plan, which was contrary to the facility's policy on comprehensive person-centered care planning.
Failure to Implement Fall Prevention Program for Residents
Penalty
Summary
The facility failed to implement its fall prevention program for two residents who experienced repeated falls. Resident 2, with a history of falling and mobility issues, had unwitnessed falls on two occasions. During an observation, it was noted that Resident 2 had a cut on the forehead and lacked a functioning call light, which is crucial for fall risk residents. The Certified Nursing Assistant (CNA) assigned to Resident 2 was unaware of the specific details of the falls and acknowledged the absence of a call light. The Interim Director of Nursing (IDON) confirmed that Interdisciplinary Team (IDT) meetings were not conducted after the falls to determine the root cause and revise the care plan, as required by the facility's Fall Management Program. Resident 3, also with a history of falling and severe cognitive impairment, had unwitnessed falls on two separate occasions. Observations revealed that Resident 3's call light was out of reach, and the bedroom door was closed, limiting supervision. The CNA assigned to Resident 3 did not recognize the resident as a fall risk, and the supervising nurse was unaware of the recent fall. The IDON stated that there were no identifying markers for fall risk residents and emphasized the importance of accessible call lights. The facility's policy indicated that high-risk residents should be identified and monitored more frequently, but no new interventions were documented in Resident 3's care plan after the falls.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to honor the rights of a resident's representative to access medical records in a timely manner. The Medical Record Department (MRD) was unable to provide evidence that the representative of a resident received the requested medical records promptly. The resident, who was admitted with a diagnosis of hemiplegia, had their representative request a copy of the medical record on June 25, 2024. However, the MRD did not complete the request form and email the corporation for approval until July 23, 2024. The corporation responded on July 30, 2024, and the representative finally received the records around August 2, 2024, which was well beyond the facility's policy of providing records within two working days. During an unannounced onsite visit on October 2, 2024, for a complaint investigation, the MRD admitted to not maintaining a log of requests for medical records and was unsure of the timeline for providing hard copies. The Director of Nursing (DON) confirmed that the facility's policy and procedure for requesting medical records, which mandates providing records within two working days, was not followed. The facility's policy, dated October 1, 2015, requires documentation of requests and timely responses, which was not adhered to in this case.
Failure to Follow Discharge Protocols
Penalty
Summary
The facility failed to follow appropriate discharge protocols for a resident diagnosed with End Stage Renal Disease. The resident was admitted to the facility and had a bed hold agreement that allowed for a seven-day hold if transferred to a hospital. Despite this agreement, the facility discharged the resident after the seven-day period without providing a 30-day notice or information on how to appeal the discharge, as required by their policy. The facility's Director of Nursing (DON) stated that the resident was discharged because the facility could not meet his needs, citing non-compliance with medications and diet. The resident was ready for discharge from the hospital on the fifth day of the bed hold, but the facility refused to readmit him, stating he had been discharged. The resident expressed distress over not being able to return to what he considered his home and was concerned about retrieving his belongings. The facility's failure to document a proper discharge process, including the lack of a 30-day notice and appeal information, was a significant oversight in their discharge protocol.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer a medication as ordered by the physician to a resident diagnosed with cirrhosis of the liver and hepatic encephalopathy. The resident was prescribed lactulose, a medication used to prevent and treat hepatic encephalopathy, to be taken 30 grams by mouth three times a day. However, a review of the Medication Administration Record (MAR) for August and September 2024 revealed that the licensed nurse did not record the administration of the morning and midday doses on specific dates, indicating that the medication may not have been given. Interviews with licensed nurses and the Director of Nursing (DON) confirmed that the MAR lacked the necessary initials or signatures to verify that the medication was administered. The facility's guidelines require that the individual administering the medication record it directly after administration. The DON acknowledged that the MAR indicated the medication was not given, and depending on the medication, a missed dose could significantly impact the resident's health.
Failure to Implement Individualized Care Plan for Resident at Risk of Elopement
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident with a history of elopement, which put the resident at risk for further elopements and injury. The resident, diagnosed with paranoid schizophrenia and bipolar disorder, was observed unattended on the patio of the secured unit. The resident had previously eloped by walking out the back door and climbing over a fence. Despite having a physician's order for a wanderguard to prevent unassisted ambulation off the unit, the system was not functional, and no alarm would activate if the resident attempted to leave. Additionally, the resident was placed on one-on-one monitoring only during the PM/NOC shift, with hourly checks during the day, which were insufficient to prevent elopement. Interviews with staff revealed that the resident frequently ambulated throughout the secured unit and liked to sit outside on the patio daily. The facility's policy required the IDT to develop a care plan considering individual risk factors and to implement immediate interventions upon a resident's return from elopement. However, the facility's wanderguard system was not operational, and the resident's care plan did not adequately address the risk of elopement, as acknowledged by the Director of Nurses. The facility had contacted a company to assess and potentially raise the height of the fence, but this action was not part of an immediate intervention plan.
Deficient Meal Preparation and Portion Control
Penalty
Summary
The facility failed to ensure that cooks followed recipes when preparing meals, which had the potential to impact the residents' nutritional status and satisfaction with the food served. During interviews conducted with nine alert and oriented residents, five expressed dissatisfaction with the food, describing it as bad, bland, and insufficient, with one resident mentioning weight loss due to the poor quality of meals. Observations revealed that raw chicken was improperly prepared by a diet assistant, who planned to cook it too early, potentially affecting its palatability by making it tough and dry. Additionally, the facility's food service director acknowledged issues with portion sizes during a previous meal service, where residents received inadequate portions of deli meat sandwiches. The spreadsheet for the meal indicated that one ounce of meat and cheese, along with accompaniments, should be provided, but the director admitted that only one slice of meat and cheese was served, and could not recall if the accompaniments were included. A sample weighing of the deli meat confirmed that the portions were below the specified amount, highlighting a failure to ensure proper portion sizes and adherence to recipes.
Failure to Supervise Resident with Suicidal History Leads to Incident
Penalty
Summary
The facility failed to provide a safe environment for a resident with a known history of suicidal behavior, resulting in the resident swallowing part of a metal fork. The resident, who had previously been admitted to the facility's secured unit, had a documented history of suicidal ideation and had previously swallowed foreign objects. Despite the care plan indicating the need for close monitoring during mealtime, the resident was left unattended, leading to the incident. The resident's care plan, initiated shortly after admission, included interventions for close monitoring during meals due to the resident's behavior of self-harm. The interdisciplinary team and nursing staff had documented the need for one-to-one supervision during meals, especially after observing the resident breaking utensils. However, on the day of the incident, the assigned CNA left the resident alone to fetch a blanket, during which time the resident swallowed a fork. Interviews with facility staff revealed that the CNA was aware of the supervision requirements but left the resident unattended, believing it would be safe to do so briefly. The facility did not have a policy available regarding safe environment or supervision during mealtime, which contributed to the oversight and subsequent incident. The resident was transferred to the hospital for the removal of the swallowed fork.
Incomplete and Inaccurate Clinical Record for Blood Draw
Penalty
Summary
The facility failed to ensure the clinical record was complete and accurate for a resident who had a blood draw performed. The resident, who had End Stage Renal Failure and was undergoing renal dialysis, reported that a phlebotomist drew blood from his fistula, despite his care plan indicating that blood should not be drawn from the arm with the graft. The medical record did not document the blood draw, although a lab result was recorded, indicating that the procedure had occurred. The phlebotomist also did not indicate the blood draw location on the Test Request Form. During a joint interview and record review, the Assistant Director of Nursing confirmed that the licensed nurse should have documented the blood draw, including the site and how the resident tolerated the procedure. The phlebotomist should have also indicated the site of the blood draw. The facility's policy on Laboratory Services did not address documentation requirements after the procedure was completed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Cajon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottonwood Canyon Healthcare Center | 0 mi | ★★★★★ | 9 | 0 |
| Country Hills Post Acute | 0.8 mi | ★★★★★ | 10 | 1 |
| Villa Las Palmas Healthcare Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Victoria Post Acute Care | 1.4 mi | ★★★★★ | 12 | 0 |
| Bradley Court | 1.7 mi | ★★★★★ | 0 | 0 |
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