Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Health Care Ctr At The Forum At Rancho San Antonio during CMS and state inspections, most recent first.
A resident with COPD, HTN, hypothyroidism, and other viral infections, who was cognitively intact per BIMS, was admitted without receiving or signing the required Admission Agreement for Skilled Nursing Facilities, which includes resident rights. Record review showed no admission agreement packet in the chart. The Director of Admission and Marketing confirmed there was no signed agreement or documentation of refusal, and the DON confirmed the packet was not provided at admission, despite facility policy requiring a signed admission agreement on file at admission and a copy given to the resident or representative.
Improper Food Storage and Unsanitary Kitchen Equipment: Surveyors found numerous expired, undated, uncovered, and spoiled food items in the kitchen, including sauces, dairy items, produce, frozen foods, and shakes. They also observed old, chipped, and worn-out kitchen equipment, including a spatula, butter spread brush, and cutting board with deep cuts and residue. Facility policy required food and non-food supplies to be clearly labeled, exposed foods to be tightly covered, and chipped service ware to be discarded.
Advance directives and POLST forms were not completed for three residents. The DON confirmed that one resident admitted with COVID-19, rhabdomyolysis, and DM2, another admitted with a scalp laceration, orthostatic hypotension, and polymyalgia rheumatica, and a third admitted with bacterial infection, asthma, and Sjogren syndrome all had no AD on file and incomplete POLST forms. The DSS was not informed about one incomplete POLST, and the MRS did not know why the forms were not completed.
A facility failed to ensure psychotropic medication use was properly monitored for three residents receiving trazodone for insomnia. For two residents, the MAR documented only YES/NO responses for inability to sleep, but did not track hours of sleep or document side effects, and the DON confirmed monitoring for trazodone side effects and sleep quantity was not being done. For another resident, a PRN trazodone order lacked the required 14-day end date, despite the facility policy limiting PRN psychotropic orders to 14 days.
Incomplete care plans were identified for four residents. One resident with migraine and insomnia had orders for topiramate and trazodone but no care plans for either condition. Another resident with atrial fibrillation and osteoporosis had orders for apixaban and raloxifene, yet no care plans for anticoagulant use or osteoporosis. Two other residents had no care plans for stage 1 heel pressure ulcers or Foley catheter use, and the DON confirmed the missing plans.
A resident with left knee pain and gout had an order for acetaminophen 325 mg, 2 tablets every 4 hours PRN for mild pain level 1-4, but the MAR showed LNs gave the medication multiple times when the resident’s pain level was above 4. The DON reviewed the MAR and confirmed the medication was administered outside the ordered pain range.
Controlled medication records were incomplete when the DON and CP destroyed expired, discharged, or discontinued meds, but the disposal sheets and resident count records lacked the DON’s signature even though both said they completed the destruction together. In addition, CDR audits for three residents did not match the MARs: doses of oxycodone and tramadol were signed out of the CDRs but not documented on the MARs or in progress notes, and the DON confirmed the medications were not accounted for.
Delayed Response to Pharmacist MRR Recommendations The DON failed to timely act on multiple CP MRR recommendations, and several were not presented to the physician or otherwise addressed. A resident on aspirin 325 mg daily had a CP recommendation to evaluate the dose, a resident on trazodone had a recommendation for psychotropic side-effect monitoring that was not documented, a resident on Eliquis 5 mg BID with AFib and low body weight had a prompt-response dose reduction recommendation that was not forwarded, and a resident with pain and gout had a recommendation for routine acetaminophen that was not presented. The DON acknowledged the delays and said the facility’s response to monthly MRRs had been late.
A facility failed to keep two residents’ drug regimens free from unnecessary medications. One resident with Afib and low body weight received apixaban 5 mg BID instead of the lower manufacturer-recommended dose, and the record lacked a risk/benefit rationale; the DON acknowledged pharmacist recommendations to reduce the dose had not been acted on. The same resident had no documented monitoring for apixaban side effects. Another resident received torsemide for HTN without hold parameters for low BP, and the DON confirmed the order lacked a parameter.
Food Served at Inadequate Temperatures: A resident reported that hot food was not hot, and another resident said meals and morning coffee were cold when served in the room. During a test tray observation, the DHN confirmed hot items were only 116.9 F to 121 F. The facility also stated it did not have a policy for food temperature at residents’ tables, and its test tray logs had no benchmark for acceptable temperatures.
An LVN entered the room of a resident with confirmed COVID-19 without the required N95, gown, gloves, or eye protection. An RN failed to change gloves during G-tube feeding care after touching contaminated items and leaving the area. An LVN used the same tissue to wipe both eyes during administration of multiple eye drops for a resident with glaucoma, and a CNA fed a resident without cleansing her hands first.
A CNA was observed standing while feeding a resident lunch in the resident’s room. During interview, the CNA said she was standing because she is short and acknowledged she could lower the resident’s bed and sit in a chair instead. The facility’s meal assistance policy states residents should be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting with meals.
A resident with urinary retention had a Foley catheter care plan that listed only a 3-day voiding diary as the intervention. The DON confirmed the voiding trial failed, but the care plan was not updated or revised, despite the facility policy requiring care plans to be revised when the desired outcome is not met.
A resident with HF, AFib, and a pacemaker had no pacemaker details in the medical record, including the manufacturer, model, serial number, date implanted, and cardiologist information. The DON reviewed the chart and confirmed the information was missing, despite the facility policy requiring these pacemaker details to be documented on admission.
Failure to complete ongoing fall risk assessment for a resident with gait and mobility issues. After a fall, the resident was assessed once, but the chart showed no further fall risk assessments. The DON confirmed the resident had not been reassessed since the fall, despite the facility policy calling for admission, quarterly, and post-fall assessments.
Missing Bed Rail Entrapment Risk Assessment: A resident with hemiplegia, hemiparesis, dysphagia, and DM had bilateral upper bed rails in place, but the facility could not provide documentation that the required bed rail entrapment risk assessment was completed. The DON confirmed the rails were present, and the ADPO stated assessments were done on admission and quarterly, but no record was available to verify completion.
A resident with hypertension experienced medication administration errors when the facility failed to adjust the timing of lisinopril as per a new physician's order. The resident received the medication twice in one day due to incorrect scheduling. Additionally, the facility failed to document the resident's refusal of the evening dose, contrary to its policy. The DON and RN confirmed these errors.
The facility failed to document the advance directive status for several residents, leaving sections of their POLST forms incomplete. This included not discussing or assisting with advance directives for some residents and failing to mark the status on the forms. The facility's policy on advance directives was not adhered to, resulting in incomplete records.
Expired OTC medications and suppositories were found in the medication room, including psyllium powder, geri-lanta, milk of magnesia, prochlorperazine, acetaminophen, bisacodyl, and hydrocortisone. The DON confirmed that licensed staff should have checked expiration dates and disposed of expired items weekly, as per facility policy.
The facility failed to comply with food safety standards, as observed during a survey. Metal bowls used for food preparation were improperly stored while still wet, contrary to the FDA Food Code and facility policy. Additionally, outdated and undated food items were found in the kitchen freezer, including yokisaba noodles and prosciutto past their use-by dates, and undated gnocchi packages. The certified dietary manager confirmed these practices were not in compliance with the facility's policies.
The facility failed to implement proper infection control practices, including a Foley catheter tube on the floor for a resident, unchanged nasal cannula tubes for another resident, and staff not performing hand hygiene after glove removal. The facility's infection preventionist and DON confirmed these practices were not acceptable and did not align with the facility's policies.
A resident's dignity and privacy were compromised when their Foley catheter drain bag was left uncovered in a wash basin on the floor. Staff interviews confirmed that the bag should have been covered with a privacy bag, as per the facility's policy on dignity.
A facility failed to provide a resident with timely notice of the ending of Medicare Part A coverage, as required by policy. The notice was given on the last day of coverage, rather than two days prior, which is necessary to allow the resident the opportunity to appeal for continued payment. This was confirmed by the facility administrator.
A resident with dementia and a history of falls had a wanderguard applied after an elopement attempt, but the MDS inaccurately recorded that the device was not used. The DON confirmed the error, noting the responsible staff member was no longer employed. Accurate MDS documentation is crucial for resident care planning.
A facility failed to implement a care plan for a resident at risk of elopement. Despite the resident's severe cognitive impairment and history of attempted elopement, the facility did not monitor or document the resident's wandering behaviors as required by the care plan. The DON confirmed the lack of implementation of these interventions, which are crucial for maintaining the resident's safety.
A resident was given pantoprazole sodium delayed release after breakfast instead of before, as prescribed. The error was observed during a medication administration and confirmed by the resident. The DON acknowledged the mistake, which was against the facility's policy and procedure.
A resident with a history of transient ischemic attack and heart disease was prescribed oxygen at 5 LPM, but observations revealed it was set at 4 LPM. Staff interviews confirmed the error, and the RN adjusted the rate to the correct setting. The facility's policy required adherence to physician's orders, which was not followed.
The facility failed to assess the appropriateness of bed rails for two residents before installation, lacking necessary documentation such as assessments, alternatives, physician orders, and care plans. The DON confirmed these omissions, which contradict the facility's policy requiring specific criteria to be met before bed rail use.
The facility did not post nurse staffing hours in a prominent place accessible to residents and visitors. The staffing information was located in a hallway blocked off due to construction, as observed during a survey and confirmed by the administrator.
A resident with Alzheimer's disease was prescribed quetiapine for behavioral disorders, but the facility failed to monitor target behaviors or use non-pharmacological approaches to minimize medication use. The pharmacy consultant's recommendations for a gradual dose reduction, approved by the MD, were not followed up, leading to unnecessary medication use.
Failure to Provide and Complete Admission Agreement and Resident Rights on Admission
Penalty
Summary
The facility failed to ensure a resident was informed of his rights upon admission by not completing the required Admission Agreement for Skilled Nursing Facilities. The resident, who had diagnoses including COPD, essential hypertension, hypothyroidism, and other viral infections, was admitted on a specified date and had a BIMS score of 15, indicating he was cognitively intact. Review of the resident’s clinical record showed that the admission agreement packet, which includes resident rights, was not present in the medical record. During a concurrent interview and record review, the Director of Admission and Marketing confirmed there was no admission agreement on file for this resident and stated that the resident had not signed the admission agreement, including the section on resident rights, and that it should have been documented if the resident did not sign. The DON also confirmed that the resident was not provided with the admission agreement packet at the time of admission. Review of the facility’s Admission Agreement policy, revised 12/2025, indicated that all residents must have a signed and dated admission agreement on file at the time of admission, that a copy must be provided to the resident or representative, and that the agreement clarifies facility services, accommodations, and the financial obligations and responsibilities of the resident. This policy requirement was not followed for this resident.
Improper Food Storage and Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to ensure food was stored, prepared, and maintained in accordance with professional food safety standards when multiple food items were found improperly labeled, expired, uncovered, or spoiled in the kitchen. During an observation with the executive chef, surveyors found items including maple syrup, Caesar dressing, cooked beets, pies, cookies, provolone cheese, tamari paste, olive oil, gravy mix, and Mighty Shakes that were past their discard or use-by dates, along with opened and undated items such as soy sauce, Dijon mustard, frozen onion rings, ice cream containers, sweet and sour sauce, prune juice, shredded carrots, diced carrots, diced onion, frozen tortillas, frozen hash browns, frozen falafels, and orange gelatin. Several food items were also uncovered, including butter pecan ice cream containers and half and half, and eight rotten iceberg lettuces were observed in the kitchen. During a later observation with the director of hospitality and nutrition, surveyors found one old and chipped spatula, one worn-out butter spread brush, and one old cutting board with deep cuts and a layer of beige residual material. The director of hospitality and nutrition confirmed the condition of these items and removed them. The facility policy stated that food and non-food supplies are to be clearly labeled, all exposed foods should be stored tightly covered, and chipped service ware should be discarded.
Advance Directives and POLST Forms Not Completed for Three Residents
Penalty
Summary
The facility failed to ensure that three residents were informed about advance directives and had completed POLST forms available in the medical record. Resident 51 was admitted with diagnoses including COVID-19, rhabdomyolysis, and type II diabetes mellitus, and review of the electronic medical record showed no advance directive and an incomplete POLST. During a concurrent interview and record review, the DON confirmed that Resident 51 had no advance directive and the POLST was not completed. Resident 17 was admitted with diagnoses including a scalp laceration, orthostatic hypotension, and polymyalgia rheumatica, and the DON confirmed during interview and record review that she had no advance directive and the POLST was not completed. Resident 59 was admitted with diagnoses including bacterial infection, unspecified asthma, and Sjogren syndrome, and the DON likewise confirmed that she did not have an advance directive and that the POLST was not completed. The DSS stated she had not been informed that Resident 17's POLST was incomplete, and the MRS stated that records were audited for POLST completion but did not know why the POLST forms for Residents 51, 17, and 59 were not completed. The facility policy stated that prior to or upon admission, Social Services or designee would inquire about the existence of any written advance directives and that this information should be prominently displayed in the medical record.
Inadequate Monitoring of Trazodone Use and PRN Order Limits
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medication use and that trazodone was monitored for effectiveness and side effects. One resident with diagnoses including depression and insomnia had a physician order for trazodone 50 mg at bedtime for insomnia, but there was no care plan developed for insomnia, no documented record of the causes or type of insomnia, and no documented monitoring for trazodone side effects. The January 2026 MAR showed only a YES or NO for inability to sleep each day, without documenting the number of hours slept to evaluate whether the medication was effective. During interview, the DON confirmed there had been no monitoring for trazodone side effects and stated the staff had not been monitoring hours of sleep. A second resident with unspecified insomnia also received trazodone 50 mg, 0.5 tablet at bedtime for insomnia, and the January 2026 MAR again documented only YES or NO for inability to sleep without tracking hours of sleep. The DON stated this monitoring was not by number of hours and was only a superficial assessment. A third resident with insomnia had a PRN trazodone order for 50 mg, 0.5 tablet every 24 hours as needed, with one repeat dose allowed, but the order did not include the required 14-day end date. The DON reviewed the order and stated it needed a 14-day end date. The facility policy stated psychotropic medication management includes adequate monitoring for efficacy and adverse consequences, and PRN psychotropic orders are limited to 14 days.
Incomplete Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans with measurable objectives, goals, and interventions were developed and implemented for 4 of 14 sampled residents. The deficiency involved Resident 1, who was admitted with diagnoses including migraine with aura and insomnia and was receiving topiramate for migraines and trazodone at bedtime for insomnia, but had no comprehensive care plans for either condition. During interview and record review, the DON confirmed there were no care plans for the resident's migraine and insomnia, although they should have been developed. Resident 38 was admitted with diagnoses including atrial fibrillation and osteoporosis without current pathological fracture and had physician orders for apixaban 5 mg twice daily for DVT prophylaxis and raloxifene 60 mg daily for osteoporosis. The record showed no care plans developed and implemented for the resident's use of apixaban or for osteoporosis. During interviews and record review, the DON stated there was no care plan for Eliquis and later confirmed there was no care plan for osteoporosis, stating care was just made on 1/29/26 and there was no osteoporosis care plan prior to 1/26/26. Resident 3 was admitted following joint replacement surgery with diagnoses including presence of a right artificial hip joint and generalized muscle weakness, and the admission record identified stage 1 pressure ulcers on both heels present on admission. The care plan did not include a pressure ulcer care plan, and the DON confirmed there was no pressure ulcer care plan done upon admission. Resident 52 was admitted with diagnoses including fracture of the right pubis and other pelvic fractures, and had an order allowing insertion of a 14fr Foley catheter for elevated post-void residuals; however, the care plan did not include a Foley catheter care plan. The DON confirmed the Foley catheter had been inserted and that no care plan had been initiated after insertion.
Pain Medication Given Outside Ordered Pain Range
Penalty
Summary
The facility failed to provide safe, appropriate pain management for one resident with left knee pain and gout. The resident had a physician order dated 2/11/25 for acetaminophen 325 mg, 2 tablets every 4 hours as needed for mild pain level 1-4. Review of the resident’s MAR from 9/2025 to 1/2026 showed that licensed nurses administered two tablets of acetaminophen 325 mg on multiple occasions when the resident’s pain level was higher than 4, including on 9/2/25, 9/9/25, 9/12/25, 9/13/25, 9/16/25, 9/19/25, 9/20/25, 10/10/25, 10/13/25, 10/24/25, 11/13/25, 12/8/25, 1/18/26, and 1/19/26. During interview, the DON reviewed the MARs and confirmed the medication was administered when the pain level was higher than ordered, and stated the licensed nurses should follow the physician order.
Incomplete controlled medication disposal and administration records
Penalty
Summary
Controlled medication records were incomplete when the facility disposed of expired, discharged, or discontinued controlled substances. During review with the DON and consultant pharmacist, the disposal records and resident count sheets for 27 medications destroyed on the identified date contained only the pharmacist’s signature and did not include the DON’s signature, even though both stated they performed the destruction together. The DON acknowledged he should have signed the records on the day of medication destruction, and the facility policy required controlled medication waste or disposal to be done in the presence of a nurse and a witness who also signs the disposition sheet. Controlled medication use audits for three residents did not reconcile between the Controlled Drugs Records and the MARs. For one resident with an order for oxycodone 5 mg half-tablet every 4 hours as needed, two doses were signed out of the CDR but not documented on the MAR, and the DON confirmed the doses should have been documented. For another resident with an order for tramadol 25 mg half-tablet every 6 hours as needed, one dose was signed out of the CDR but not documented on the MAR or in the nursing progress notes. For a third resident with an order for oxycodone 5 mg every 3 hours as needed, two doses were signed out of the CDR but not documented on the MAR or in the progress notes, and the DON confirmed the medications were not accounted for. The facility policy stated the person administering medication must initial the MAR and record the date, time, signature, and title after giving each medication.
Delayed Response to Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist’s monthly medication regimen review recommendations were acted upon and responded to in a timely manner. The Director of Nursing stated he was the primary person responsible for acting on the pharmacist’s recommendations, but he acknowledged that recommendations from November and December 2025 were delayed because he was too busy to work on them. He also stated that the Consultant Pharmacist had informed him on 1/20/26 that there were pending reports from October through December 2025, and he had only started working on them after that visit. The Consultant Pharmacist stated that communication about follow-up could be better and that the DON was not very good at getting back to her. For Resident 10, the Consultant Pharmacist recommended on 12/14/25 that the physician evaluate the daily aspirin 325 mg regimen because the dose was greater than 100 mg and could increase the risk of bleeding complications, but the recommendation had not been presented to the physician more than a month later. For Resident 1, who had diagnoses including depression and insomnia and was ordered trazodone 50 mg at bedtime, the care plan called for monitoring every shift for psychotropic side effects, yet the record did not show that staff were monitoring for trazodone side effects. The Consultant Pharmacist recommended on 12/14/25 that trazodone side effects be monitored, but the DON verified that this had not been acted upon. For Resident 38, who had atrial fibrillation and weighed less than 60 kg, the record showed an order for Eliquis 5 mg twice daily. The manufacturer’s prescribing information and both pharmacists’ reviews indicated that if apixaban is being used for atrial fibrillation in a resident with dose-limiting characteristics such as age 80 or older and body weight 60 kg or less, the recommended dose is 2.5 mg twice daily. The Consultant Pharmacist made a clinical priority recommendation on 1/12/26 requesting prompt response, but the DON confirmed the recommendation had not yet been provided to the physician. For Resident 29, who had pain in the left knee and gout and an order for acetaminophen 325 mg, 2 tablets every 4 hours as needed, the pharmacist recommended on 11/11/25 that routine acetaminophen 650 mg at 8 p.m. be considered because the resident frequently received PRN acetaminophen at night, but the DON confirmed that this consultation report had not been presented to the physician.
Unnecessary anticoagulant dosing, missing anticoagulant monitoring, and absent hold parameters for diuretic order
Penalty
Summary
The facility failed to ensure that Resident 38’s drug regimen was free from unnecessary medication use when apixaban was ordered at 5 mg twice daily despite the resident being over the age threshold and weighing less than 60 kg, which matched the manufacturer’s criteria for the lower 2.5 mg twice-daily dose for atrial fibrillation. The resident’s record did not contain a risk/benefit assessment or rationale for continuing the higher dose. The consultant pharmacist had recommended dose reduction on two occasions, and the DON acknowledged the recommendations had been received but had not been acted upon, leaving the higher dose in place. The facility also failed to monitor Resident 38 for signs and symptoms related to apixaban use. Review of the January 2026 MAR and physician’s orders showed no monitoring for side effects related to the anticoagulant. During interview and record review, the DON stated he did not see an order for side-effect monitoring and acknowledged that it was missing. Facility policy required staff and the physician to monitor for possible complications in residents receiving anticoagulation therapy and to discuss signs such as excessive bruising, hematuria, hemoptysis, or other evidence of bleeding before the next scheduled dose. The facility further failed to include hold parameters for Resident 7’s torsemide order. Resident 7 had diagnoses including unspecified atrial fibrillation and osteoporosis without current pathological fracture, and the order was for torsemide 20 mg, 2 tablets by mouth daily for hypertension. Review of the January 2026 MAR and physician’s order showed no parameters to hold the medication when blood pressure was low. The DON confirmed the absence of holding parameters and stated there should be a parameter. Facility policy required periodic re-evaluation of medications and monitoring for undesired complications.
Food Served at Inadequate Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature. A resident stated on 1/26/26 that the hot food was not hot. During an observation of a test tray with the DHN on 1/28/26, the brisket, macaroni and cheese, and burger were measured at 117.9 F, 121 F, and 116.9 F, and the DHN confirmed those temperatures. On 1/30/26, the DHN stated the facility did not have a policy on food temperature served at residents’ tables. Another resident stated on 1/30/26 that the food was cold, including hot food, morning coffee, eggs, bacon, and sausages served in the room. Review of the facility’s Food and Nutrition: Test Tray Evaluation Logs showed temperatures were taken on test trays, but there was no benchmark to determine what temperature was acceptable.
Infection Control Lapses During PPE Use, Tube Feeding, Eye Drop Administration, and Hand Hygiene
Penalty
Summary
Proper infection prevention and control practices were not followed when an LVN entered the room of a resident with confirmed COVID-19 without the required PPE. Resident 51 was admitted with a diagnosis of COVID-19 and had a physician order for airborne precautions. During observation, the LVN was inside the resident’s room with the door open and was not wearing the required N-95 mask, gown, gloves, or goggles. The DSD and the LVN both confirmed the PPE was not worn, and the IP stated the expectation was to follow airborne precaution PPE requirements. In another event, RN B did not change gloves during enteral feeding care for Resident 2, who had diagnoses including hemiplegia, hemiparesis following cerebral infarction, dysphagia, and type II diabetes mellitus, and had an order for bolus tube feeding. During observation, RN B moved a trash bin, checked G-tube residual, went to the bathroom to discard the residual, then continued with flushing and administering formula without changing gloves after touching contaminated items or after leaving the room area. RN B confirmed she did not change gloves after touching the trash bin or after going to the bathroom, and the IP stated gloves should be changed, hand hygiene performed, and new gloves applied when moving from dirty to clean tasks. Additional infection control lapses were observed during medication administration and mealtime assistance. LVN C administered three different eye medications to Resident 4 for glaucoma and used the same tissue to wipe excess liquid from both eyes after each medication, which he later confirmed and acknowledged should have been done with a separate tissue for each eye to prevent cross-contamination. CNA F also fed Resident 18 without cleansing her hands after pushing another resident’s wheelchair and sitting down in the dining room. The CNA stated she should have washed or sanitized her hands before feeding, and the IP stated staff should cleanse their hands before feeding residents.
Failure to Preserve Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat Resident 23 with respect and dignity when CNA D stood while feeding the resident lunch in the resident’s room. During a dining observation, CNA D was seen standing while assisting Resident 23 with lunch, and in a concurrent interview she stated she was standing because she is short. CNA D acknowledged that she could lower Resident 23’s bed so she could sit on a chair while feeding the resident. Review of the facility’s Assistance with Meals policy stated that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals.
Incomplete Foley Catheter Care Plan Not Revised After Failed Voiding Trial
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan for one sampled resident with a Foley catheter for urinary retention. Resident 33 was admitted with a diagnosis including urinary retention, and the physician’s order dated 1/1/26 directed a Foley catheter 16Fr to be changed per MD schedule and as needed for obstruction. The resident’s care plan, dated 12/15/25, identified the problem as altered bladder elimination with a Foley catheter for urinary retention, but the only intervention listed was a 3-day voiding diary to establish a pattern and need for bladder training/toileting programs. During a concurrent interview and record review on 1/28/26 at 1:28 p.m., the DON reviewed the Foley catheter care plan and confirmed there was only one intervention. The DON stated the 3-day voiding trial failed and the care plan should have been updated. The facility policy titled Care plan, Comprehensive, Person-Centered states that care plans are developed and implemented for each resident, are revised as residents’ conditions change, and are updated when the desired outcome is not met.
Missing Pacemaker Documentation
Penalty
Summary
The facility failed to ensure necessary care and services were provided for one resident with diagnoses of heart failure, atrial fibrillation, and presence of a cardiac pacemaker when the resident’s pacemaker information was not found in the medical record. The record review showed that the resident’s pacemaker details, including the manufacturer, model, serial number, date implanted, and name of the cardiologist, were missing. During interview, the DON reviewed the resident’s records and was unable to locate the pacemaker information, and stated that it should be available in the medical record. The facility policy for care of a resident with a pacemaker required documentation of the cardiologist’s contact information, pacemaker type, lead type, manufacturer and model, serial number, date of implant, and paced rate upon admission.
Failure to Complete Ongoing Fall Risk Assessment
Penalty
Summary
The facility failed to assess fall risk for one resident after a fall on 5/28/25. Resident 36 was admitted with a diagnosis of abnormalities of gait and mobility, and a nursing progress note documented that on 5/28/25 she stood and transferred from her wheelchair to a walker in the dining room, lost balance, and fell onto her left side. Her clinical record showed she was assessed for fall risk when she fell, but there were no fall risk assessments completed after that date. During interview, the DON reviewed the record and confirmed the resident had not been assessed for fall risk since after 5/28/25, and stated residents should be assessed on admission, every quarter, and after a fall. The facility policy on Fall Risk Assessment stated nursing staff, with the attending physician, consultant pharmacist, therapy staff, and others, will identify and document resident fall risk factors and establish a resident-centered falls prevention plan based on assessment information.
Missing Bed Rail Entrapment Risk Assessment
Penalty
Summary
The facility failed to ensure proper use of bed rails for one of nine residents, Resident 2, because there was no documented evidence that a bed rail entrapment risk assessment was completed. Resident 2 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, and type II diabetes mellitus. During a concurrent observation and interview, the DON confirmed that Resident 2 had bilateral upper bed rails in place. The physician's order dated 12/9/25 authorized use of bed rails per bed rail assessment for two transfer bars related to the resident's hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side. During interviews and record review, the ADPO stated that entrapment risk assessments for bed rails were completed upon admission and quarterly, but was unable to provide documentation showing that Resident 2's assessment had been completed. The DON later confirmed that the ADPO could not provide documentation of the bed rail entrapment risk assessment. The facility policy stated that a bed rail gap evaluation would be completed by maintenance in collaboration with licensed nurses and documented.
Medication Administration Errors and Documentation Failures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with hypertension. The resident had a physician's order for lisinopril, a medication used to lower blood pressure, to be administered once daily in the morning. On a specific day, the physician changed the administration time to the evening, but the staff incorrectly scheduled the new time to start on the same day, resulting in the resident receiving the medication twice in one day. The Director of Nursing (DON) and the registered nurse (RN) involved confirmed the error, acknowledging that the new administration time should have started the following day. Additionally, the facility documented that the resident received the evening dose of lisinopril, although the resident had refused it, as she had already taken the medication in the morning. The facility's policy requires documentation of medication refusal, but there was no record of the refusal in the resident's medical record. The DON confirmed the lack of documentation and acknowledged that the refusal should have been recorded according to the facility's policy.
Failure to Document Advance Directive Status
Penalty
Summary
The facility failed to ensure that five residents had proper documentation regarding their advance directive status. For Residents 13, 24, 334, and 336, there was no evidence that the facility discussed or assisted in executing an advance directive, nor was there documentation of a request for a copy of an executed advance directive. Specifically, Resident 13's POLST form had all options for advance directive status left blank, and there was no documentation in the clinical record regarding advance directives. Similarly, Resident 24's POLST form indicated that an advance directive was not available, and there was no documented discussion or assistance provided. Resident 334's POLST form also noted no advance directive, with no evidence of facility engagement on the matter. Resident 336's POLST form was incomplete, with all options left blank. Additionally, Resident 3's POLST form was incomplete, with no checked boxes indicating the status of their advance directive. The admissions staff confirmed that Resident 3's advance directive was not in the system, and none of the checkboxes in section D of the POLST were marked. The facility's policy requires that the existence of an advance directive be determined upon admission and documented in the medical record, with assistance offered if needed. However, this policy was not followed, leading to incomplete documentation and a lack of clarity regarding the residents' advance directive status.
Expired Medications Found in Facility's Medication Room
Penalty
Summary
The facility failed to ensure proper storage of medications in the medication room, as observed during a survey. Expired over-the-counter (OTC) medications, including psyllium powder, geri-lanta, and milk of magnesia, were found in the OTC medication supply cabinet. These medications had expiration dates ranging from May to June 2024. The Director of Nursing (DON) confirmed these findings and acknowledged that licensed nursing staff should have verified expiration dates and removed expired medications weekly. Additionally, expired suppositories were found in the same medication room. These included prochlorperazine, acetaminophen, bisacodyl, and hydrocortisone suppositories, with expiration dates as far back as March 2023. A box of benacalorie nutritional supplement was also expired. The DON confirmed these observations and reiterated that licensed staff should have checked expiration dates and disposed of expired medications and supplements weekly. The facility's policy and procedure for the disposal of expired medications, revised in February 2023, indicated that discontinued or outdated medications should be placed in a designated, secure location for destruction.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey. The first issue identified was the improper storage of bowls used for food preparation and service. During an observation, several metal bowls were found stacked while still wet, which contradicts the facility's policy and the FDA Food Code that requires equipment and utensils to be air-dried before being stored. The certified dietary manager confirmed the improper practice, acknowledging that the bowls should have been allowed to air dry before stacking. The second issue involved the storage of undated and outdated food items in the facility's kitchen freezer. During a kitchen tour, several food items were found to be past their manufacturer's use-by dates, including a bag of yokisaba noodles and packages of prosciutto. Additionally, packages of gnocchi with spinach were found without any use-by dates, likely due to being removed from their original packaging. The certified dietary manager confirmed these items were beyond their use-by dates or undated and should be discarded, which was not in compliance with the facility's policy requiring all stored foods to be labeled and dated.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances, which could lead to the spread of infections and cross-contamination among residents. For Resident 332, the tubing of a Foley catheter was observed lying on the floor next to the resident's bed. The licensed vocational nurse (LVN) acknowledged that the tubing should have been placed above the floor to prevent infection. Similarly, for Resident 334, nasal cannula tubes were found on the floor and had not been changed according to the physician's orders. The LVN confirmed that the nasal cannula tubing should have been placed in a bag when not in use and changed weekly. Additionally, during a medication administration observation, an LVN failed to perform hand hygiene after removing gloves, which is a critical step in preventing infection. The LVN admitted to not washing hands after glove removal, which is against the facility's policy. Furthermore, a phlebotomist was observed walking in the hallway with gloves on, which is not in line with standard infection control practices. The phlebotomist acknowledged the mistake and stated that gloves should be removed, and hands should be washed before entering the hallway. The facility's infection preventionist and director of nursing confirmed that these practices were not acceptable and did not align with the facility's policies and procedures. The facility lacked a specific policy covering the placement of nasal cannula and oxygen tubing, which contributed to the oversight. The facility's policies on hand hygiene and glove use were not followed, leading to potential risks of infection spread among residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident 332, by not covering the resident's Foley catheter drain bag. Resident 332 was admitted to the facility with a diagnosis that included a fracture of the superior rim of the left pubis and had a physician's order for a Foley catheter. During an observation, it was noted that the resident's Foley catheter drain bag was left uncovered and placed in a wash basin on the floor next to the resident's bed. Interviews with the licensed vocational nurse, the infection preventionist, and the director of nursing confirmed that the Foley catheter drain bag should have been covered with a privacy bag to maintain the resident's dignity and privacy. The facility's policy and procedure on dignity, revised in February 2021, also indicated that urinary catheter bags should be covered to promote dignity and respect for residents.
Failure to Provide Timely Medicare Coverage Termination Notice
Penalty
Summary
The facility failed to provide timely notice of the ending of Medicare Part A coverage to a resident, which is a requirement to allow the resident the opportunity to appeal for continued payment by Medicare. Specifically, the Skilled Nursing Facility Beneficiary Notification Review (SNF BNR) for the resident indicated that the last day of Medicare Part A Skilled Services coverage was on the same day the notice was signed, which was 5/23/2024. According to the facility's policy, the Notice of Medicare Non-Coverage (NOMNC) should be given no later than two days before the termination of services. However, in this case, the notice was provided on the last day of coverage, not allowing the required 48-hour notice period. This discrepancy was confirmed during an interview with the facility administrator, who acknowledged the failure to adhere to the policy.
Inaccurate MDS Assessment for Resident with Wanderguard
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, identified as Resident 19, which led to a deficiency. Resident 19, who had diagnoses including dementia and a history of falling, required assistance with personal care. An incident occurred where Resident 19 attempted to elope, prompting the physician to order a wanderguard, a device that activates an alarm when a resident attempts to leave a safe area. The family consented to the application of the wanderguard on Resident 19's left wrist. However, the MDS assessment conducted on a later date inaccurately indicated that the wanderguard was not used, despite the device being in place. During an interview and record review, the Director of Nursing (DON) confirmed that Resident 19 was indeed wearing a wanderguard and that the MDS was incorrect. The DON acknowledged that the MDS should have reflected the use of the wanderguard. The staff member responsible for the inaccurate MDS was no longer employed at the facility and unavailable for comment. According to the Resident Assessment Instrument Manual, alarms such as wanderguards should be accurately recorded in the MDS to ensure proper monitoring and care planning for residents.
Failure to Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to implement the elopement risk care plan for a resident identified as an elopement risk. The resident, who has severe cognitive impairment due to dementia and a history of falling, attempted to elope on a previous occasion. Following this incident, a wanderguard was applied to the resident's wrist as a preventive measure. However, the facility did not follow through with the care plan interventions, which included identifying patterns of wandering, monitoring the resident's location throughout shifts, and documenting wandering behavior. During an interview and record review, the Director of Nursing confirmed that the interventions outlined in the care plan were not implemented. The resident's treatment record lacked documentation of wandering behaviors or exit-seeking episodes, despite the care plan's requirement for such monitoring. The facility's policy on wandering and elopements emphasizes the importance of identifying residents at risk and implementing strategies to maintain their safety, which was not adhered to in this case.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for medication administration for a resident, identified as Resident 340. The resident was prescribed pantoprazole sodium delayed release 40 mg to be taken every morning before breakfast. However, during a medication administration observation, it was noted that the medication was given after breakfast by a licensed vocational nurse (LVN A). This was confirmed by Resident 340 during an interview, who stated that all medications were administered after breakfast, contrary to the physician's orders. The director of nursing (DON) acknowledged that the medication should have been administered before breakfast, as per the medical doctor's order. The facility's policy and procedure, revised in July 2016, requires nursing staff to review the overall situation for the resident to ensure that any related issues are addressed. This oversight in following the prescribed medication schedule had the potential to affect the health and well-being of Resident 340, who had an intact cognition as indicated by a BIMS score of 14/15.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to adhere to physician's orders for administering oxygen to a resident, identified as Resident 24. The resident was admitted with diagnoses including transient ischemic attack, thrombocytosis, and atherosclerotic heart disease. According to the physician's orders dated 6/23/2024, the resident was to receive oxygen at 5 liters per minute (LPM) via nasal cannula continuously, with the option to increase to 8 LPM if oxygen saturation fell below 90 or if there was increased shortness of breath. However, during observations on 7/15/2024 and 7/17/2024, it was noted that the resident's room air concentrator was set at 4 LPM, which was below the prescribed rate. Interviews with staff, including a licensed vocational nurse and a registered nurse, confirmed the discrepancy in the oxygen rate setting. The registered nurse acknowledged the error and adjusted the oxygen rate to the correct 5 LPM as per the physician's order. The director of nursing also confirmed that the staff should have followed the physician's order to set the oxygen rate at 5 LPM. The facility's policy and procedure for oxygen administration emphasized verifying and following physician's orders, which was not adhered to in this instance.
Failure to Assess Bed Rail Appropriateness
Penalty
Summary
The facility failed to determine the appropriateness of bed rails for two residents before installation, which could potentially lead to harm from improper use. For Resident 17, there was no bed rail assessment, documentation of alternatives used, physician order, or care plan prior to the installation of the bed rails. Similarly, for Resident 81, there was no bed rail assessment, documentation of alternatives used, physician order, or care plan prior to the installation. During an interview, the DON confirmed the absence of these necessary documents for both residents. The facility's policy on bed safety and bed rails, revised in August 2022, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal regulations by not posting the nurse staffing hours in a prominent place that is readily accessible to residents and visitors. During a survey, it was observed that the posting for the licensed and unlicensed nursing staff's total number and actual hours worked was not visible at the nurses' station. Upon inquiry, the administrator explained that the staffing information was posted in a hallway currently blocked off due to construction and painting activities.
Failure to Monitor and Reduce Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically quetiapine, due to several oversights. There was no documented evidence of target behavior monitoring for the use of quetiapine, nor were non-pharmacological approaches utilized to minimize the need for this medication. Additionally, the pharmacy consultant's recommendations for a gradual dose reduction of quetiapine were not followed up, despite the medical doctor's approval of these recommendations. The resident in question was admitted with a diagnosis of Alzheimer's disease and was prescribed quetiapine for behavioral disorders. The facility's director of nursing acknowledged the lack of monitoring for target behaviors, the absence of non-pharmacological interventions, and the failure to follow up on the pharmacy consultant's and MD's recommendations. This lack of action resulted in inadequate monitoring and the continued use of unnecessary medication for the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cupertino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Los Altos Post-acute | 1.2 mi | ★★★★★ | 2 | 0 |
| Sunny View Manor | 1.5 mi | ★★★★★ | 0 | 0 |
| Cupertino Healthcare & Wellness Center | 1.8 mi | ★★★★★ | 25 | 0 |
| Idylwood Care Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Sunnyvale Post-acute Center | 1.9 mi | ★★★★★ | 3 | 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 June 2026) and official state health department websites.