Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenfield Care Center Of Fullerton, Llc during CMS and state inspections, most recent first.
The facility did not follow its own Change of Condition policy requiring every-shift assessments and documentation for 72 hours after a significant change, specifically for residents with newly identified skin issues. Three residents with impaired decision-making capacity developed new or changed skin breakdowns, documented on SBAR forms, but their records lacked evidence of the required 72-hour, every-shift monitoring. A treatment nurse reported that she only completed weekly skin progress notes unless conditions worsened and believed there was no requirement for 72-hour, every-shift documentation for skin-related changes, while an RN acknowledged the policy but stated that licensed nurses were not expected to complete these monitoring notes because treatment nurses were viewed as responsible for treatment and monitoring.
A resident with ESRD and a right upper arm AV shunt had a care plan and MD order directing staff not to obtain BP on the right arm, but nursing staff repeatedly took right-arm BP readings anyway. During interview and record review, an LPN confirmed the right arm should not have been used because it was the site of the resident’s dialysis access.
Incorrect Wound Treatment Administration for a Stage 3 Heel Pressure Injury: A resident with a Stage 3 pressure injury to the heel did not receive wound care as ordered. During observation, an LVN applied Thera honey before collagen powder, left a significant amount of collagen on the bed instead of the wound bed, and used calcium alginate with silver even though the order did not specify it. The wound care PA stated the ordered sequence was collagen first, then Thera honey, then alginate, and the DON stated treatments were expected to be given as listed in the physician order.
Inaccurate Post-Fall Risk Assessment: A resident with no decision-making capacity and moderate cognitive impairment had a post-fall risk assessment that incorrectly documented no recent falls, even though the resident had fallen. The error resulted in a low fall-risk score instead of a high-risk score, and RN and DON interviews confirmed the assessment was inaccurate.
Dialysis care deficiencies occurred for two residents. One resident with ESRD had monthly labs drawn at the dialysis center, but the results were not obtained from the center or placed in the chart. Another resident with a right-arm AV shunt had an order not to take BP on that arm, yet nursing staff documented BP readings on the shunt arm on six occasions. The DON and an LVN verified the findings.
A facility failed to follow its med administration policy for two residents receiving dialysis. For one resident with ESRD, BP meds were sent with the resident to dialysis and later charted by facility nurses even though there were no physician orders for that process and the dialysis record did not show administration. For another resident, carvedilol and calcium acetate were given after the scheduled time following a dialysis trip, outside the facility’s required one-hour window.
Medication administration errors exceeded the allowed rate, with an observed error rate of 8%. An RN gave artificial tears incorrectly by administering two drops in each eye instead of the ordered one drop in both eyes, and an LVN gave Creon without food or a meal even though it was ordered to be given with meals. Both nurses verified the errors during the observation.
Improper Medication Storage and Disposal: A resident with severe cognitive impairment had a weekly medication box on the overbed table containing multiple capsules in several compartments, and an LVN stated the meds were not familiar and did not need to be at bedside. In addition, an opened single-use package of collagen powder was found in Medication Cart A, and expired BBL culture swabs were found in Medication Storage Room A.
Kitchen Food Safety and Sanitation Deficiencies: A clean blender was observed stored wet with visible water inside and the lid on, and the DSS confirmed it had been washed but not air-dried before storage. In a separate observation, a serving scoop was found with food residue and a melted white handle, and the DSS verified the finding. The facility’s policy and USDA Food Code requirements for air-drying and clean food-contact surfaces were not followed.
Inaccurate Blood Sugar Documentation for a Resident at Dialysis: The facility documented daily blood sugar checks in the Vitals Summary and MAR for a resident while he was offsite at dialysis. The record showed the resident left for HD before the documented times on multiple occasions, and an RN verified the resident was at the dialysis center when the BG readings were charted.
Staff failed to follow infection control practices during several observed events. A kitchen aide picked up trash from the floor and touched kitchen surfaces without washing hands, an LPN placed a resident’s wound-bearing heel on a pillow before hand hygiene during wound care for a resident with a Stage 3 pressure injury and no decision-making capacity, and an activity assistant handled soiled linen with bare hands and returned to the activity area without hand hygiene.
A resident diagnosed with unspecified dementia had anti-dementia meds ordered after a neurology visit, but the facility did not have the complete neurology progress notes in the chart and did not develop a dementia-specific care plan. RN and DON interviews confirmed the resident’s dementia diagnosis, the missing consult notes, and the absence of an IDT care plan addressing the resident’s dementia.
Care Plan Not Updated After Resident Fall: A resident with moderate cognitive impairment and high fall risk sustained a fall, but the LTC plan was not revised to reflect the new fall episode or the current interventions and physician recommendations. An RN and the MDS Assistant both verified the omission, and the Administrator and DON acknowledged the findings.
The facility failed to clean and sanitize the ice machine according to the manufacturer's instructions, risking illness from contaminated ice. The Maintenance Director admitted to not mixing descaling and sanitizing solutions correctly, affecting all residents receiving food prepared in the kitchen.
The facility failed to implement control measures to prevent Legionella growth in the water system and did not ensure proper hand hygiene during wound care for a resident. The Maintenance Supervisor could not provide evidence of planned control measures, and an LVN was observed not performing hand hygiene between glove changes during wound care, contrary to facility policy.
The facility failed to accommodate the ethnic food preferences of its residents, particularly those who preferred Korean breakfast. Despite the majority of residents being Korean-speaking, the facility did not provide Korean menus or meals, as confirmed by the DSS and DON. Residents expressed dissatisfaction with the American breakfast options and were not offered Korean alternatives, contrary to the facility's policy for Nutrition Care - Resident Food Preferences.
A resident with a Stage 3 pressure ulcer was found on a low air loss mattress set incorrectly for their weight, despite being unable to communicate comfort levels. The mattress was set for a weight of 175 pounds, while the resident weighed 99 pounds. The LVN and DON confirmed the error, acknowledging the need for the mattress to be set according to the resident's weight.
A resident was observed receiving oxygen at six liters per minute via nasal cannula, contrary to the physician's order for two liters per minute. The facility's policy requires adherence to physician orders, and any changes should be documented and communicated to the physician. The discrepancy was confirmed by the IP and acknowledged by the DON.
A facility's medication error rate was found to be 7.41% due to an LVN administering incorrect supplements to a resident, which did not match the physician's orders. The LVN gave Extra Strength Glucosamine Hcl with MSM and Vision Formula 50+ instead of the prescribed glucosamine-chondroitin and lutein supplements.
Two residents in an LTC facility experienced significant medication errors. One resident received blood pressure medications despite having a systolic blood pressure below the physician-ordered threshold. Another resident was administered carvedilol even though their heart rate was below the ordered parameter. Both errors were confirmed by the DON and involved staff.
A resident refused a laxative medication, but an LVN documented it as administered, resulting in an inaccurate MAR. The DON confirmed that refusals should be documented.
The facility failed to monitor antibiotic use according to McGeer's criteria, leading to inappropriate prescriptions for two residents and lack of verification for another. Antibiotics were prescribed without meeting infection criteria, and there was no documentation of physician notification. The IP confirmed the findings, and the DON acknowledged the issue.
A facility failed to report an abuse allegation to local law enforcement as required by its policy. A resident alleged mistreatment by staff, but the report sent to CDPH did not include notification to law enforcement. The administrator confirmed this oversight.
A facility failed to explain an arbitration agreement to a resident with moderate cognitive impairment who did not understand English. The resident signed the document without comprehension, as it was presented in English by staff who did not speak the resident's language. The Director of Admissions acknowledged the oversight and the need for documents in the resident's language.
Failure to Monitor and Document Change of Condition for New Skin Issues
Penalty
Summary
The facility failed to follow its Change of Condition policy requiring licensed nurses to continue assessment and documentation every shift for 72 hours after a significant change, specifically for residents with new skin issues. The policy, dated 4/2025, states that licensed nurses must contact the physician when there is a significant change of condition, inform family, and document all nursing actions, physician orders, and assessment information, with continued assessment and documentation every shift for 72 hours or until the condition is stable. For three residents who lacked capacity to make medical decisions, SBAR Communication Forms documented new or changed skin conditions: one resident with various small superficial skin breakdowns on the left and right buttocks, another with MASD to the sacrococcyx area, and a third with a small area of skin breakdown on the right perianal fold. However, their medical records did not contain evidence that these changes in condition were monitored and documented every shift for at least 72 hours after the initial observations. During interviews, the Treatment Nurse stated that an SBAR/Change of Condition Report was created whenever a new skin issue was identified, but she believed she was only required to document weekly progress notes on existing skin conditions under treatment, unless the condition worsened or deteriorated. She further stated there was no requirement for licensed nurses to monitor and document every shift for 72 hours after a change of condition related to skin issues. Another RN acknowledged the facility’s policy to monitor residents for at least 72 hours after a change of condition and confirmed that the three residents had change of condition reports related to skin issues, but stated that licensed nurses were not expected to complete monitoring progress notes every shift for 72 hours because treatment nurses were responsible for providing treatment and monitoring as ordered. The Administrator was informed of and acknowledged these findings.
Failure to Follow AV Shunt Blood Pressure Restriction
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident with end stage renal disease and a right upper arm AV shunt. The resident’s care plan, initiated on 8/27/25, included an intervention not to obtain blood pressure on the right arm where the AV shunt was located. The resident also had a physician’s order dated 8/26/25 directing nursing staff not to obtain blood pressure on the right arm, and a later order dated 8/29/25 for hemodialysis twice weekly on Monday and Friday at 0430 hours. Despite the care plan and physician’s order, the nursing staff obtained the resident’s blood pressure on the right arm on multiple occasions. The record showed right-arm blood pressure readings on 8/28/25, 8/30/25, 9/4/25, 9/5/25, and twice on 9/6/25. During an interview and concurrent medical record review on 9/10/25, LVN 1 verified that staff should not have obtained the resident’s blood pressure using the right arm, the location of the AV shunt, in accordance with the resident’s ESRD care plan.
Incorrect Wound Treatment Administration for a Stage 3 Heel Pressure Injury
Penalty
Summary
The facility failed to ensure the necessary care and services related to pressure injuries were provided to one of two sampled residents reviewed for pressure injuries. The resident had a diagnosis of a Stage 3 pressure injury to the right heel and no capacity to understand and make medical decisions. The care plan addressed the right heel wound and included reassessment by the wound care PA with orders to cleanse with normal saline, pat dry, apply collagen, Thera honey, and alginate, then cover with a dry sterile dressing/kerlix for 21 days. The physician's order also directed cleansing with normal saline, pat dry, apply collagen, Thera honey, alginate, and dry sterile dressing/kerlix every day shift for 21 days. During a wound treatment observation, the LVN prepared normal saline, calcium alginate dressing with silver, collagen powder, and Thera honey gel. After cleaning the right heel, the LVN applied Thera honey gel to the wound bed and then applied collagen powder on top of the Thera honey. A significant amount of the collagen powder was observed on the resident's bed directly under the right heel rather than on the wound bed. After hand hygiene and new gloves, the LVN proceeded to apply the calcium alginate dressing, and was stopped when the powder on the bed and the minimal amount on the wound bed were verified. The LVN then reapplied the collagen powder to the wound bed, again on top of the Thera honey gel, and completed the dressing with calcium alginate, dry dressing, and kerlix. During interview, the LVN stated Thera honey gel should be applied first, followed by collagen powder, and verified that she had applied the treatments in that order. The LVN also verified she used calcium alginate with silver even though the order did not specify it. The wound care PA stated the collagen powder should have been applied first, followed by Thera honey gel, then the alginate dressing, and that calcium alginate with silver was not needed for the wound. The DON stated wound treatments were expected to be administered as listed in the physician's order and that questions should be clarified, and the DON acknowledged the findings.
Inaccurate Post-Fall Risk Assessment
Penalty
Summary
The facility failed to ensure the environment remained free from accident hazards for one sampled resident reviewed for falls because the resident’s post-fall risk assessment was not completed accurately. Resident 43 was admitted to the facility and had no capacity to understand and make decisions per the H&P examination dated 12/31/24. The resident’s MDS assessment showed a BIMS score of 9, indicating moderate cognitive impairment. Resident 43’s post-fall risk assessment dated 8/7/25 marked “no falls in the past six months” under history of falls, even though the resident had a fall episode on 8/7/25. The assessment gave a total score of 9, placing the resident at low risk for falls. During interview and record review, RN 1 verified the assessment was inaccurate and stated that if the fall had been counted, the score would have been 10, which would place the resident at high risk for falls. The DON also reviewed the documentation and stated she did not notice the inaccuracy in the post-fall assessment.
Dialysis Care Deficiencies
Penalty
Summary
The facility failed to provide necessary dialysis care and services for two residents who required hemodialysis. The facility's dialysis services policy stated that care coordination may include communication with the dialysis unit and review of laboratory values obtained for dialysis residents, including BUN, creatinine, sodium, potassium, calcium, magnesium, phosphate, hemoglobin, and hematocrit. It also stated that the dialysis access site required avoidance of blood pressure readings, venipunctures, and trauma to the access extremity. For one resident with ESRD who received hemodialysis on Mondays, Wednesdays, and Fridays, the dialysis center documented that monthly laboratory tests were obtained, but the resident's medical record did not show that the laboratory results were obtained from the dialysis center or placed in the chart. The ADON reviewed the dialysis communication record and verified the labs were documented as obtained, and the DON stated the RN supervisor or receiving licensed nurse was responsible for following up to obtain the results and place them in the resident's medical record. For another resident with an AV shunt in the right upper arm and an order not to obtain blood pressure on that arm, nursing staff documented blood pressure measurements on the right arm on six occasions. The resident also had an order to monitor the AV shunt every shift and received hemodialysis twice weekly. During interview and record review, an LVN and the DON verified that blood pressure should not have been taken on the arm with the AV shunt and confirmed the documented right-arm readings.
Medication Administration Errors for Residents on Dialysis
Penalty
Summary
The facility failed to ensure pharmaceutical services were provided in accordance with its medication administration policy for two residents receiving dialysis care. The policy stated medications must be administered by the same person preparing the dose, must not be prepared in advance, must be given within one hour before or after the ordered time, and must be documented immediately by the licensed nurse who administered them. The report identified failures involving Resident 10 and Resident 91 during dialysis-related medication administration and documentation. For Resident 10, who had ESRD and received hemodialysis on Mondays, Wednesdays, and Fridays, the facility sent scheduled blood pressure medications with the resident to the dialysis center after staff were informed that the resident’s blood pressure dropped during dialysis. The ADON stated there were no physician orders directing that the medications be sent out, and the facility did not document the dialysis center call or notify the physician. The resident’s MAR showed amlodipine and hydralazine were documented as administered by facility nurses at 0900 hours on dialysis days, while the RN stated he placed the medications in a pouch and sent them with the resident, and the dialysis communication record did not show the medications were administered at the dialysis center. For Resident 91, the facility did not administer carvedilol and calcium acetate within the ordered time frame. The resident left the facility for dialysis at 0400 hours and returned at 0840 hours, and the MAR audit showed carvedilol and calcium acetate were documented at 0840 and 0841 hours even though both were scheduled for 0730 hours. RN 3 confirmed the resident had been away for dialysis and stated the medications should have been administered within one hour of the scheduled time, but the facility failed to do so.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, and the observed medication error rate was 8%. During medication administration observations, two of three licensed nurses were found to have made errors for two sampled residents. One RN administered artificial tears ophthalmic solution to a resident by giving two drops in the right eye and two drops in the left eye, even though the physician’s order was for one drop in both eyes two times a day for dry eyes. The resident stated she always received two drops in each eye, and the RN later verified she had not followed the physician’s order. A second resident was observed receiving Creon delayed-release capsules from an LVN without food or a meal present at the bedside, even though the physician ordered the medication to be given with meals. The LVN verified the medication was not administered with meals or food. Facility policy required medications to be administered according to physician orders and established medication administration procedures, including eye drop instructions and medications that must be given with meals.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to provide necessary pharmacy services to ensure proper storage and disposal of medications. During an initial tour, a medication box container labeled with each day of the week was observed on a resident's overbed table. The resident had a BIMS score of six, indicating severe cognitive impairment, and stated he was not aware of the medication box container. On concurrent observation and medical record review with an LVN, the container was found to hold multiple capsules in several day compartments, and the LVN stated she was not familiar with the medications inside and that there was no need to have the medications at the resident's bedside. The DON was later informed and acknowledged these findings. The facility also failed to properly store and dispose of medications in medication areas. In Medication Cart A, an opened individual package of [NAME] collagen powder, labeled as single use only, was observed and verified by an RN. In Medication Storage Room A, nine sealed individual packages of BBL culture swab were found with an expired date. The RN verified the expired items, and the Administrator and DON were informed and acknowledged the findings.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety and sanitation guidelines were followed in the kitchen. During an initial kitchen tour, a clean blender was observed stored wet with visible water inside and the lid on. The Director of Dietary Services verified that the blender had been used earlier, washed, and was not air-dried before being stored. The facility’s policy stated that equipment should be cleaned, sanitized, air-dried, and reassembled after each use, and the USDA Food Code requires cleaned equipment and utensils to be air-dried or stored in a self-draining position that allows air drying. During a later kitchen observation, a serving scoop was found with food residue and a melted white handle. The Director of Dietary Services verified the finding. The facility’s policy stated that plastic-ware or dishware that has lost its glaze or is chipped or cracked must be disposed of, and the USDA Food Code requires food-contact surfaces and utensils to be clean to sight and touch. The Administrator and Director of Dietary Services were informed of and acknowledged the findings during interview.
Inaccurate Blood Sugar Documentation for Resident at Dialysis
Penalty
Summary
The facility failed to ensure the medical record was accurately maintained for one of 21 sampled residents, Resident 91. Resident 91 had physician orders for hemodialysis twice weekly on Monday and Friday at 0430 hours and for daily blood sugar checks with notification parameters for abnormal results. The record showed that on 9/1/25, 9/5/25, and 9/8/25, the facility documented blood sugar checks in the Vitals Summary and MAR at times when Resident 91 was not in the facility. Resident 91's Nurse's Dialysis Communication Record showed that he left the facility for dialysis before the documented blood sugar times and did not return until later that morning on each of those days. On 9/9/25, RN 3 was interviewed and the medical record was reviewed concurrently; RN 3 verified that Resident 91 was at the dialysis center during the times the facility documented obtaining the blood sugar readings. The report states that the facility documented blood sugar values of 115 mg/dL on 9/1/25, 117 mg/dL on 9/5/25, and 107 mg/dL on 9/8/25 despite the resident being offsite at dialysis.
Infection Control Practices Not Followed During Kitchen, Wound Care, and Linen Handling
Penalty
Summary
The facility failed to implement infection control practices during multiple observed events involving kitchen staff, nursing staff, and an activity assistant. In the kitchen, Kitchen Aide 1 picked up a small piece of white paper from the floor with a bare hand, touched the lid of the gray trash receptacle, discarded the paper, and then touched an empty metal cart without washing her hands. The facility’s sanitation and infection control handwashing policy stated food service workers must keep their hands and exposed arms clean and that hands must be properly and frequently washed to prevent cross contamination. The DSS and Kitchen Aide 1 verified the observation, and the DSS stated the floor was not considered clean and that staff must wash their hands after picking up anything from the floor. During wound care for Resident 2, who had no capacity to understand and make medical decisions and had a Stage 3 pressure injury on the right heel, LVN 3 cleansed the wound with normal saline and gauze, then placed the resident’s right heel on a pillow before performing hand hygiene. The pillow made direct contact with the wound bed. LVN 3 stated that if the wound touched anything in the resident’s environment, it should be cleansed again before medication was applied. In a separate observation, an Activity Assistant took soiled linen from a resident with her bare hand and carried it to Shower Room A, then returned to the Activity Room without washing or sanitizing her hands. The DON and Administrator were informed and acknowledged the findings, and the DON stated staff were supposed to perform hand hygiene after handling soiled linens.
Failure to Develop Dementia Care Plan and Obtain Neurology Notes
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with unspecified dementia. The resident was admitted to the facility and later had a diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The medical record also showed the resident had no capacity to understand and make medical decisions. After a neurology appointment, the resident returned to the facility with a physician note and orders, and the preliminary clinical conclusion indicated anti-dementia medications should be started. The resident’s record showed orders for galantamine hydrobromide and memantine, and the medications were administered on the MAR, except for two days. However, the record did not show the facility developed or implemented a care plan to address the resident’s dementia. The record also did not contain the complete neurology progress notes from the appointment, and there was no documentation that the facility attempted to obtain those notes. RN and DON interviews confirmed the resident had dementia, the care plan had not been developed, and the neurology progress notes were not in the chart.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to revise Resident 43’s comprehensive plan of care to reflect a change in condition after the resident sustained a fall on 8/7/25. Resident 43 was admitted to the facility with no capacity to understand and make decisions, and a later MDS assessment showed a BIMS score of 9, indicating moderate cognitive impairment. The resident’s plan of care, revised on 7/15/25, addressed the resident’s high risk for falls, but it did not include the recent fall episode or the current care needs and interventions related to that event. Facility staff confirmed the omission during interviews and record review. An RN verified that the long-term care plan for fall risk was not revised to reflect the fall, and stated that licensed nurses must revise the long-term care plan for new fall episodes. The MDS Assistant also verified that the plan was not revised after the fall and stated that the new interventions and physician recommendations should be added when revising the fall-risk care plan. The Administrator and DON were informed of and acknowledged the findings.
Improper Ice Machine Sanitization
Penalty
Summary
The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's instructions, posing a risk of illness to residents from contaminated ice. During an observation and interview with the Maintenance Director, it was revealed that the facility had one ice machine, and the instructions for cleaning and sanitizing were displayed on an inner panel of the machine. The instructions specified that descaling and sanitizing solutions should be mixed with water. However, the Maintenance Director admitted to not mixing these solutions correctly as per the manufacturer's instructions. This oversight affected all 93 residents who received food prepared in the facility's kitchen, as they were potentially exposed to improperly sanitized ice.
Infection Control Deficiencies in Water Management and Hand Hygiene
Penalty
Summary
The facility failed to maintain infection control practices, specifically in preventing the growth of Legionella bacteria in the water system and ensuring proper hand hygiene during wound care. The facility did not have a comprehensive plan or implemented control measures to prevent the growth of Legionella and other opportunistic pathogens in the water system, as required by CMS guidelines. Although the Maintenance Supervisor stated that a risk assessment was conducted and water testing occurred every six months, there was no evidence of planned and implemented control measures to inhibit microbial growth. Additionally, the facility failed to ensure proper hand hygiene practices during wound care for a resident. The resident, who had a sacrococcyx Stage III wound, was observed receiving wound care from an LVN who did not perform hand hygiene between glove changes. Despite the facility's policy requiring hand hygiene before and after glove use, the LVN changed gloves without washing hands, potentially compromising infection control. Both the LVN and RN assisting in the procedure acknowledged the lapse in hand hygiene during the care process.
Failure to Provide Ethnic Food Preferences
Penalty
Summary
The facility failed to honor and facilitate the residents' preferences and choices for food, specifically for three residents who preferred Korean breakfast. The Dietary Services Supervisor (DSS) confirmed that all residents were served breakfast from the American menu, and Korean menus were not provided in Korean language, despite the majority of residents being Korean-speaking. Resident 22 expressed a preference for Korean breakfast and the ability to read a Korean menu, but was not offered these options. Similarly, Resident 70 stated she would like a Korean breakfast but was not offered one, and Resident 61, who had a diagnosis of unspecified protein-calories malnutrition, expressed dissatisfaction with the American breakfast options provided, preferring Korean food instead. Interviews and observations revealed that the facility did not take into account the ethnic food preferences of its residents, as outlined in their policy for Nutrition Care - Resident Food Preferences. The DSS and the Director of Nursing (DON) acknowledged that a significant portion of the resident population spoke and read primarily Korean, yet the facility did not provide Korean menus or meals. This oversight resulted in residents not being able to choose food items according to their ethnic preferences, as evidenced by Resident 61's actions of modifying her meal with Korean condiments and expressing her preference for Korean food.
Improper Mattress Setting for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set appropriately according to a resident's weight, which is crucial for pressure ulcer care and prevention. The resident, who weighed 99 pounds, was observed lying on a mattress set to a comfort level corresponding to a weight of 175 pounds. This discrepancy was noted during multiple observations over several days. The facility's policy and procedure for pressure-reducing mattresses, as well as the operating instructions for the mattress system, indicated that the mattress should be set according to the resident's weight. The resident in question had a Stage 3 pressure ulcer and was totally dependent on staff for bed mobility, with documented memory problems and an inability to make medical decisions. Despite these conditions, the mattress was not set to the appropriate level for the resident's weight. The Licensed Vocational Nurse (LVN) confirmed the incorrect setting and acknowledged that the resident could not verbalize comfort levels, necessitating the mattress to be set according to the resident's weight. The Director of Nursing (DON) was informed and acknowledged the findings.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to the physician's order for oxygen therapy for a resident, identified as Resident 17, which was observed during a survey. The facility's policy and procedure for oxygen therapy, revised in January 2024, mandates that oxygen should be administered as ordered by the physician. On September 3, 2024, Resident 17 was observed receiving oxygen at six liters per minute via nasal cannula, contrary to the physician's order dated August 24, 2024, which specified oxygen administration at two liters per minute continuously. Additionally, the order allowed for titration up to five liters per minute via mask if the resident's oxygen saturation level fell below 90%. During an interview and concurrent medical record review, the Infection Preventionist (IP) confirmed that Resident 17 was not receiving oxygen as per the physician's order. The IP stated that any increase in oxygen should be documented in the medical record and the physician should be notified. The Director of Nursing (DON) was informed of these findings and acknowledged the discrepancy between the observed oxygen administration and the physician's order.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the observed rate being 7.41%. This deficiency was identified during a medication administration observation involving an LVN and a resident. The LVN administered medications that did not align with the physician's orders for the resident. Specifically, the LVN gave one tablet of Extra Strength Glucosamine Hcl with MSM and one softgel of Vision Formula 50+ dietary supplement, which were not in accordance with the prescribed glucosamine-chondroitin and lutein supplements. The discrepancy was confirmed when the LVN reviewed the medication labels and compared them to the resident's physician's orders. The physician had ordered glucosamine-chondroitin and lutein supplements, but the LVN administered different supplements that did not match these orders. This failure to administer medications as prescribed had the potential to cause negative outcomes for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 28 and 62, were free from significant medication errors. For Resident 28, the medical record review revealed that on July 19, 2024, the resident was administered amlodipine besylate and losartan potassium-HCTZ despite having a systolic blood pressure (SBP) of 102 mmHg, which was below the physician-ordered parameter of holding the medication for an SBP less than 110 mmHg. The Director of Nursing (DON) confirmed that these medications should not have been administered under these conditions. Similarly, for Resident 62, the medical record review showed that on September 3, 2024, the resident was given carvedilol despite having a heart rate of 57 beats per minute, which was below the ordered parameter of holding the medication for a heart rate less than 60 beats per minute. Both RN 5 and the DON verified that the medication should have been withheld according to the physician's order, acknowledging this as a medication error incident.
Failure to Document Medication Refusal
Penalty
Summary
The facility failed to accurately document a medication refusal for a resident, leading to an inaccurate medication administration record. During an observation, a Licensed Vocational Nurse (LVN) prepared a laxative medication for a resident who refused it because he was leaving for an appointment. Despite the refusal, the LVN documented the medication as administered in the resident's medical record. A subsequent review of the Medication Administration Record (MAR) confirmed the documentation error. The Director of Nursing (DON) later confirmed that medication refusals should be documented as such.
Failure to Monitor Antibiotic Use According to McGeer's Criteria
Penalty
Summary
The facility failed to monitor and address the use of antibiotics according to McGeer's criteria for infection in two residents and did not verify if another resident's condition met the criteria. Specifically, Resident 24 and Resident 73 were prescribed antibiotics without meeting the McGeer's criteria for infection. Resident 24 was given a triple antibiotic ointment for an open blister on the leg, and Resident 73 was prescribed a triple antibiotic ointment for a skin tear in the occipital area. In both cases, the symptoms did not align with the criteria for infection, and there was no documentation of physician notification regarding the inappropriate use of antibiotics. Additionally, Resident 29 was prescribed Amoxicillin for swelling and tenderness in the right lower gum, but the facility did not document whether the condition met McGeer's criteria for infection. The Infection Preventionist (IP) confirmed these findings and acknowledged the lack of documentation and follow-up with the physician. The Director of Nursing (DON) was informed and acknowledged the findings as well. These failures had the potential to lead to the use of antibiotics when not indicated, increasing the risk of developing antibiotic-resistant bacteria.
Failure to Report Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. This deficiency occurred when the facility did not report an abuse allegation to the local law enforcement for a resident who alleged mistreatment. The facility's Abuse and Neglect Prevention Management policy, revised in August 2018, mandates that all allegations of abuse or mistreatment be reported per state law, including to local law enforcement. On September 3, 2024, a resident alleged that three staff members were mean and rough with her. The facility's administrator was informed of these allegations, and a report was faxed to the California Department of Public Health (CDPH). However, the report did not indicate that local law enforcement was notified. The administrator confirmed that the facility did not notify local law enforcement of the abuse allegation.
Failure to Explain Arbitration Agreement in Resident's Language
Penalty
Summary
The facility failed to ensure that the arbitration agreement was properly explained to a resident, identified as Resident 12, who had moderate cognitive impairment and did not understand English. The facility's policy required that the arbitration agreement be explained in a form, manner, and language that the resident and their representative could understand. However, this was not adhered to in the case of Resident 12. The resident's medical records indicated a BIMS score of 9, suggesting moderate cognitive impairment, and her Facesheet listed her son and three daughters as responsible parties. During an interview, Resident 12 confirmed that she signed the arbitration agreement but stated that she did not understand the document as it was presented in English, a language she did not know. The Director of Admissions acknowledged that the front desk staff, who did not speak Korean, presented the document to Resident 12. The Director also admitted that Resident 12 was not fully alert at the time of signing and that the facility should have provided the arbitration agreement in Korean to ensure comprehension by Korean-speaking residents and their families.
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Illustrative
What surveyors actually found near you
We read the 6,090 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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 Fullerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terrace View Care Center | 0 mi | ★★★★★ | 28 | 0 |
| The Pavilion At Sunny Hills | 0 mi | ★★★★★ | 9 | 0 |
| St Elizabeth Healthcare Center | 0.4 mi | ★★★★★ | 25 | 0 |
| Park Vista At Morningside | 1.1 mi | ★★★★★ | 21 | 0 |
| St. Catherine Healthcare | 1.7 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.