Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Heritage Gardens Health Care Center during CMS and state inspections, most recent first.
Unsanitary kitchen equipment and improper food storage: The DOK observed dish-drying racks with heavy buildup and soiling, a beverage station with residue and spills, and multiple kitchen items including a flat-top griddle, 6-burner stove, two ovens, and a back plate behind the stove with grease, burnt-on residue, rust, and debris. The DOK confirmed the areas were not clean and acknowledged facility policies for Ranges and Ovens, Sanitization, and Food Receiving and Storage were not followed. Several food items, including juice, honey, gravy beef, buns, and tortilla chips, were also found stored directly on the floor in the dry storage room.
Ineffective Pest Control Program: Surveyors observed a live bug resembling a cockroach in a conference room, and staff interviews revealed repeated cockroach sightings in staff, visitor, and resident bathrooms, as well as throughout the facility. A pest control report also documented active American cockroach activity in the dining area, boiler room, billing office restroom, and occupied resident rooms, despite the facility’s monthly pest control service.
Advance directive information was not properly handled for three residents. One resident was not provided advance directive information on admission and had an incomplete, unsigned acknowledgement form with no Social Services documentation. Two other residents had discrepant or incomplete POLST/advance directive records, and the chart lacked copies of existing advance directives even though both residents stated they had them. The DON acknowledged the facility did not have the documents on file and that the policy was not followed.
A resident with a urinary catheter had an uncovered drainage bag attached to the bed, and urine was visible to anyone entering the room or passing in the hallway. CNA acknowledged the bag was not covered, and the IP and DON stated catheter drainage bags were supposed to have a privacy or dignity bag to keep the urine from being seen and to maintain resident dignity.
Failure to protect a resident from verbal abuse occurred when a resident with a known history of verbal aggression was observed yelling profanities and insults at another resident while both were in the same room. The aggressive resident had a care plan addressing verbal aggression, and staff acknowledged awareness of the behavior, but the Admin stated the expected supervision and interventions to protect residents from abuse were not done; the DON agreed the abuse P&P was not followed.
Failure to complete an SCSA after a resident’s fall with fracture. A resident with a hx of falls, L hip joint replacement, muscle weakness, and difficulty walking fell in the bathroom, reported blacking out, complained of R wrist pain, hit her head, and was sent to the ER; she later returned with a splint for a distal radius fracture. The DON stated the significant change MDS should have been completed after the change in condition was identified, but MDS staff did not think it was required.
A resident with schizoaffective disorder, anxiety disorder, and delirium had an MDS coded as not showing hallucinations even though the MAR documented repeated auditory hallucinations, including within the 7-day look-back period. The DON acknowledged the MDS was completed incorrectly, and the SSD stated she coded Section E without reviewing the MAR. The resident was also observed stating that someone in his room was choking and tripping him when no one else was present.
A resident with vitamin D deficiency was ordered Cholecalciferol 2000 units PO daily, but an LVN omitted the medication during a med pass and later acknowledged missing it on the MAR. The DON stated licensed nurses were expected to follow MD orders and ensure scheduled meds were administered and documented accurately, and the facility policy required meds to be given in accordance with prescriber orders.
Foley catheter care was not properly monitored for a resident with a history of UTI, sepsis, and bacteremia. Staff observed the urinary drainage tubing touching the floor, and a CNA stated she was unsure of the correct positioning. The physician ordered Foley care every shift for patency, placement, and positioning, but the TAR had blanks on multiple shifts. The IP, DON, and facility policy all stated the tubing and drainage bag should be kept off the floor.
A resident with epilepsy, anxiety disorder, and altered mental status was observed in bed with the call light wedged between the mattress and side rail and not within reach. The resident said she had a headache, had not notified staff, and did not know where the call light was. An LPN verified the call light was inaccessible, and the DON and Admin acknowledged the facility policy requiring the call light to remain within easy reach was not followed.
Survey Results Not Posted in Accessible Location: Residents reported they could not easily find the facility’s most recent survey results, and the DON could not identify where they were posted. The ADMIN said the survey was usually kept by the bulletin board near the nursing station, but it was not there during inspection; instead, a 3-ring binder was typically used. Review of the facility P&P showed the survey results were supposed to be maintained in an area frequented by residents, such as the main lobby or activity room, but this was not followed.
A CNA engaged in a verbal altercation with a resident who has hemiplegia and hemiparesis, after the CNA forcefully pulled the resident's pillow, prompting the resident to use profanity. The CNA responded with repeated expletives, escalating the situation and violating facility policy requiring staff to treat residents with respect and dignity. The incident was witnessed by another staff member and confirmed by facility leadership.
The facility failed to store the ice scoop for the kitchen's ice machine in a clean and sanitary manner, as required by policy. The ice scoop was found in an uncovered container, posing a risk of contamination. Staff acknowledged the oversight, which could impact the health and safety of all residents receiving food and beverages from the kitchen.
The facility failed to follow infection control policies, including not changing or labeling medical equipment for residents and neglecting hand hygiene practices. A resident's CVC dressing was overdue for a change, and another's oxygen tubing was not changed for 17 days. Staff did not perform hand hygiene during medication administration and meal assistance, increasing infection risks.
A facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days for a resident admitted to hospice care, delaying the update of the resident's care plan. The resident, with cerebrovascular and atherosclerosis heart disease, was enrolled in hospice, but the SCSA was not conducted, resulting in a delay of over six months. This oversight was acknowledged by the MDS Nurse, indicating non-compliance with facility policy and OBRA regulations.
Two residents in the facility had inaccuracies in their MDS assessments. One resident with Type 2 diabetes mellitus did not have their insulin injections coded, despite receiving them on six days within the look-back period. Another resident on a prescribed antibiotic regimen for osteomyelitis had their antibiotic use omitted from the MDS assessment, despite daily administration. The errors were acknowledged by the MDS nurses, and the facility's policy for certifying assessment accuracy was not followed.
A facility failed to ensure a physician's order for a Speech Therapy evaluation was communicated to the hospice provider for a resident with severe cognitive impairment and difficulty chewing. The order, made on November 23, 2024, was not documented as completed, and the facility's policy requiring coordination with hospice was not followed, potentially risking the resident's health.
The facility failed to implement RNP recommendations for two residents, leading to a deficiency in care. A resident with muscle weakness did not receive recommended ambulation with a walker, and another with muscle contracture did not receive ROM exercises. The DON and DOR were unaware of these recommendations due to poor communication between departments, resulting in a lack of documented evidence and non-compliance with the facility's policy on Restorative Nursing Services.
A resident was administered oxygen therapy without a physician's order, contrary to the facility's policy. The resident, who had dementia and other medical conditions, was observed using a nasal cannula with an oxygen concentrator. The DON confirmed the absence of a physician's order and acknowledged the policy was not followed.
A facility failed to ensure a Licensed Vocational Nurse (LVN) maintained an active license, allowing the LVN to work with an expired license. The Director of Nursing (DON) admitted responsibility for checking licenses but did not verify expiration dates, leading to the LVN working without a valid license. The job description required current licensure, which was not followed.
A facility failed to adhere to its policy for blood glucose monitoring for a resident with type 2 diabetes, leading to a delayed blood sugar check. The resident, who had moderate cognitive impairment, was supposed to have blood sugar checks before meals and at bedtime, but the check was conducted later than scheduled. This failure potentially led to a change in the resident's condition and transfer to a hospital for evaluation.
A facility failed to follow its ADL policy, resulting in a resident with dementia having long and unclean fingernails. The resident required assistance with personal hygiene, and both the Administrator and Resident Assessment Coordinator acknowledged the issue, stating it was the CNAs' responsibility. The facility's policy required providing necessary services for grooming and hygiene.
A CNA wrapped a resident's waist and legs in linen sheets, failing to follow the facility's restraint policy. The resident, with severe cognitive impairment and other medical conditions, was found in this state by another CNA, who reported it to an LVN. The facility's policy states that restraints should only be used for safety and well-being after other alternatives have been tried, and never for staff convenience. The DON confirmed the policy was not followed.
Unsanitary kitchen equipment and improper food storage
Penalty
Summary
The facility failed to keep food service equipment and food storage areas in sanitary condition. During observation with the Director of Kitchen (DOK), a stack of 18 dish-drying racks in the dishwashing area was found with heavy mineral buildup, visible grime, worn surfaces, scratches, abrasions, discoloration, and soiling on the interior dividers that contact food-contact items. In the beverage service station, the coffee and hot-water dispensers had visible liquid residue on the exterior surfaces, stains and spills were present on the counter beneath them, the disposable liner under the hot-water dispenser contained dried spills and debris, and the condiment organizer was cluttered with loose packets scattered around it. The DOK confirmed these areas were not clean. In the kitchen, the flat-top griddle had visible layers of grease, black burnt buildup, and dark discoloration across the cooking surface and surrounding areas. The 6-burner stove had accumulated burnt grease and food debris across multiple surfaces. Oven #1 had accumulations of burnt food particles, grease stains, dark residue, and debris on the interior surfaces, including the oven floor, side panels, and racks, with pieces of aluminum foil scattered on the oven floor. Oven #2 had heavy blackened residue, accumulated grease, burnt-on food buildup, and rust along the interior walls, racks, and bottom tray. The back metal plate behind the stove also had visible layers of grease stains and dark discoloration. The DOK confirmed these items were not clean and stated that the ovens had not been used for some time. Record review showed the facility’s Dietary Cleaning Schedule and Deep Cleaning Schedule documented cleaning dates for the stove, grill, burners, and ovens, but the DOK was unable to explain the significant accumulation of burnt grease, food debris, rust, and discoloration observed on the equipment and surrounding surfaces. The facility’s policies for Ranges and Ovens, Sanitization, and Food Receiving and Storage were reviewed, and the DOK acknowledged the policies were not followed. In the dry storage room, several food items were found stored directly on the floor, including a box of apple juice, boxes of honey and gravy beef instant, hot dog buns in a crate, and tortilla chips in another crate. The DOK stated the items had been delivered earlier that morning and acknowledged they should have been stored off the floor upon receipt.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program when a live bug resembling a cockroach was observed crawling on the floor underneath a conference table in the conference room during surveyor observation. During interviews, a CNA stated she had seen cockroaches in staff and visitor restrooms on three or four occasions over the past five months, another CNA stated she had seen cockroaches in resident bathrooms on a few occasions and usually killed them without reporting them, and a housekeeper stated she saw cockroaches in the facility at least once a week in various resident and staff restrooms throughout the hallways. The Administrator stated the facility used a monthly pest control company. A pest control service report dated March 30, 2026, documented American cockroach activity in the dining area, boiler room, and near the billing office restroom, and also noted staff reports of cockroach activity in occupied resident rooms that could not be treated because residents were in the rooms. Facility policy stated the facility shall maintain an effective pest control program and that pest control services were provided by the contracted company. Another policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment.
Advance Directive Information Not Properly Documented or Obtained
Penalty
Summary
The facility failed to follow its advance directive policy for Resident 14 on admission. Resident 14 was admitted with diagnoses including arthrogryposis multiplex congenita, muscle weakness, abnormalities of gait and mobility, and post-polio syndrome. The resident’s advance directive acknowledgement form showed that the resident answered no to having an existing advance directive and yes to wanting additional information, but the form was incomplete, not signed by the resident, and the section for referral to Social Services was left blank. During interview, Resident 14 stated that no advance directive existed and that the resident did not recall receiving advance directive information from the facility. Record review and interview with the SSD showed there was no social service note or progress note documenting that advance directive information had been provided to Resident 14. The SSD stated that it was the facility’s policy for Social Services to ask residents on admission whether they had an advance directive or wanted information about one, and stated that this policy was not followed. The Administrator also reviewed the facility’s Advance Directives policy, which required written information to be provided upon admission and required Social Services to inquire about the existence of an advance directive and offer assistance if none existed. For Resident 30, the medical record contained discrepant information about whether an advance directive existed. The POLST indicated no advance directive, while the Advance Directive Acknowledgement indicated the resident did have an advance directive and was initialed by the resident. However, the sections for a copy provided and a copy requested were left blank, and there was no advance directive on file in either the electronic record or paper chart. The DON stated she did not know why the forms conflicted and acknowledged the facility did not have an advance directive on file. When asked, Resident 30 stated that an advance directive had been created in the past and that a nephew had a copy. For Resident 73, the POLST was incomplete because Section D regarding whether the resident had an advance directive was left blank. The DON stated the form was not completed correctly and that Section D should have been completed by an RN. The DON also stated the facility was not aware the resident had an advance directive and that it was missed. Resident 73 stated that she had both an advance directive and a POA, but the medical record did not contain an advance directive acknowledgement or a copy of an existing advance directive. In both Resident 30’s and Resident 73’s cases, the facility’s policy required Social Services to inquire about advance directives and obtain copies when they existed, but the records reviewed did not show that this occurred.
Uncovered urinary drainage bag exposed urine to hallway view
Penalty
Summary
The facility failed to maintain dignity for Resident 115 when the resident’s urinary collection bag was left uncovered and urine was visible to individuals entering the room and to people passing in the hallway. Resident 115 was admitted with diagnoses including UTI, dementia, muscle weakness, and difficulty walking. During observation on May 4, 2026, at 12:33 PM, the resident was lying in bed with the room door open, and the urinary collection bag attached to the side of the bed was uncovered, with 150 ml of yellow urine clearly visible from the hallway. During a concurrent observation and interview on May 4, 2026, at 12:36 PM, CNA 4 acknowledged that the urinary collection bag was not covered and that the urine inside could be seen from the hallway. The facility’s IP later stated that urinary catheter drainage bags were supposed to have a privacy bag applied so the urine could not be seen, and that covering the urine was important to maintain residents’ dignity. The DON also stated that every resident with a urinary catheter was supposed to have a dignity bag covering the urinary collection bag to maintain dignity and respect. The facility did not provide a copy of the policy and procedure regarding dignity bags.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to follow its abuse policy and procedure for one resident with a known history of verbal aggressive behaviors when that resident was observed verbally abusing another resident. Resident 52 was admitted with diagnoses including cerebral infarction, type 2 diabetes, and muscle weakness, and the care plan dated October 31, 2025, identified a potential for verbal aggression related to poor impulse control with selective staff, with interventions including medication administration, monitoring for side effects and effectiveness, and providing positive feedback for good behavior and emphasizing the positive aspects of compliance. During an observation in the 300-Hall unit, Resident 52 was seen verbally abusing Resident 56 while both residents were lying in their beds in the same room. Resident 52 called Resident 56 an asshole and a liar and told him to turn his TV down. When a CNA intervened and asked about the behavior, Resident 52 continued yelling profanities at Resident 56, including, fuck you, stop talking shit, put your fucking headphones on, and you're being a smartass. Resident 56 had diagnoses including encephalopathy, type 2 diabetes, and acute respiratory failure with hypoxia. The CNA stated staff were aware of Resident 52's verbal aggression and tried to keep a close eye on him and provide positive feedback for good behavior. The Administrator stated the facility's expectation was to provide supervision and interventions necessary to protect residents from abuse, including resident-to-resident altercations, and stated those interventions were not done. The DON agreed that the policy was not followed.
Failure to Complete Significant Change MDS After Fall With Fracture
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for Resident 53 after the resident experienced a fall with a fracture. Resident 53 was admitted with diagnoses including history of falling, presence of a left artificial hip joint, muscle weakness, and difficulty walking. The most recent MDS before the fall was a quarterly assessment dated one day earlier, which coded no impairment in the upper extremities and indicated the resident had not had any falls since admission, entry, reentry, or the prior assessment. On April 9, 2026, staff documented that Resident 53 fell in the bathroom, reported blacking out, was alert and oriented x 3, complained of right wrist pain, stated she hit her head on the wall, and had a bump on the right temple. The resident was sent to the ER and later returned with a splint placed to the right wrist for a distal radius fracture, with instructions to follow up with orthopedics. The DON stated a significant change MDS should have been completed after the change in condition was identified and documented, but it was not. MDS 1 stated she believed a significant change assessment was only needed if more than two areas of the MDS declined or improved and did not think one was needed for this fall with fracture.
MDS Not Accurately Coded for Hallucinations
Penalty
Summary
The facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for Resident 30’s behavior and emotional mood assessment. Resident 30 was admitted with diagnoses including schizoaffective disorder, anxiety disorder, and delirium due to a known psychological condition. During a concurrent observation and interview on May 4, 2026, Resident 30 stated that an individual was in his room choking him, tripping him, and talking to him, although no one else was present in the room and he did not have a roommate. Resident 30’s RAI-MDS assessment dated [DATE] showed Section E, E0100 Potential indicators of psychosis, was coded as “none of the above,” with hallucinations not indicated. However, Resident 30’s physician’s orders included an order dated August 26, 2024, to document episodes of auditory hallucinations every shift. The care plan titled Schizoaffective disorder m/b auditory hallucinations also directed staff to assess hallucinations when apparent and document episodes of auditory hallucinations. Review of Resident 30’s MAR for April 1, 2026 through April 30, 2026 showed 74 documented instances of auditory hallucinations in April 2026, including 13 instances within the 7-day look-back period for the MDS assessment. During interview and record review, the DON acknowledged the MDS was completed incorrectly for Section E because it did not indicate hallucinations. The SSD stated she completed Section E and incorrectly coded it because she did not look at the MAR when determining whether the resident was experiencing hallucinations.
Missed Ordered Vitamin D Medication
Penalty
Summary
The facility failed to follow its medication administration policy for one sampled resident when LVN 1 did not administer Cholecalciferol as ordered by the physician. Resident 116 was admitted with a diagnosis that included vitamin D deficiency, and the physician’s order dated April 27, 2026 directed that Cholecalciferol 2000 units be given by mouth daily as two 1000-unit tablets. During a medication pass observation on May 7, 2026, at 8:12 AM, LVN 1 prepared medications for Resident 116 but did not administer Cholecalciferol. Later that day, LVN 1 reviewed the MAR and acknowledged the medication had been omitted, stating, “I missed that medication during the pass.” The DON stated that licensed nurses were expected to follow physician orders and verify that all scheduled medications were administered and documented accurately during each medication pass, and that the facility’s policy required medications to be administered in accordance with prescriber orders.
Foley Catheter Tubing Left on Floor and Ordered Monitoring Not Documented
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured when staff failed to monitor the indwelling Foley catheter for Resident 115 as ordered. Resident 115 was admitted with diagnoses that included urinary tract infection, sepsis, and bacteremia. During observation, the resident was lying in bed with the urinary collection bag attached to the side of the bed, and the tubing leading to the Foley catheter was touching the floor. During the same observation, CNA 4 stated she was unsure how the Foley catheter tubing was supposed to be positioned and acknowledged that it was touching the floor. The physician ordered Foley catheter care on April 23, 2026, including monitoring for patency, placement, and positioning every shift. Review of the TAR showed blanks for Foley catheter care on 2 of 15 shifts in May and 3 of 22 shifts in April. The Infection Preventionist stated the drainage bag should be positioned below the bladder and the tubing should not be touching the floor, and the DON stated the tubing should be off the floor and positioned appropriately for infection control. The facility policy also stated catheter tubing and drainage bags are to be kept off the floor.
Call Light Not Accessible to Resident
Penalty
Summary
The facility failed to ensure a resident’s call light was within reach when Resident 91 was observed lying in bed with the call light wedged between the mattress and the side bed rail and not accessible. Resident 91, who had diagnoses including epilepsy, anxiety disorder, and altered mental status, stated she had a headache and said she had not informed staff because she had not seen her nurse and did not know where her call light was located. During the same observation, LVN 1 verified that the call light was stuck between the mattress and bed frame and had difficulty pulling it free, stating it should not have been there and that it needed to remain accessible to the resident at all times. The LVN acknowledged that Resident 91 was unable to use the call light to request assistance for her headache. The Administrator and DON later reviewed the facility’s policy, which required the call light to be within easy reach when a resident is in bed, and both acknowledged the policy was not followed.
Survey Results Not Posted in Accessible Location
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives. During the Resident Council Meeting on May 5, 2026, residents voiced concerns about the visibility and accessibility of the survey results, and multiple residents stated they did not know where the results were posted. During interviews, the DON acknowledged that the most recent survey must be visibly posted in an unobstructed area accessible to residents and the public, but could not identify or demonstrate where it was posted. The ADMIN stated the survey was usually posted by the bulletin board in front of the nursing station, but when the surveyor, ADMIN, and DON went to that location, the survey was not posted there. The ADMIN said a 3-ring binder containing the survey results was typically placed at that location but could not account for its absence. Review of the facility policy showed that a copy of the most recent survey and related reports was to be maintained in a 3-ring binder in an area frequented by most residents, such as the main lobby or resident activity room, and the ADMIN acknowledged the policy was not followed.
CNA Engages in Verbal Altercation with Resident, Violating Dignity and Respect
Penalty
Summary
A Certified Nursing Assistant (CNA) engaged in a verbal altercation with a resident who had hemiplegia and hemiparesis. The incident began when the CNA pulled the resident's pillow forcefully, which upset the resident and led him to use profanity toward the CNA. In response, the CNA used expletives multiple times in return, escalating the exchange of offensive language. This interaction was witnessed by another staff member and was later validated by the CNA involved. The facility's policy requires all employees to treat residents with kindness, respect, and dignity, and prohibits the use of expletives in interactions with residents. The Director of Nursing and Administrator confirmed that the CNA's actions were in violation of this policy. The resident involved was alert and oriented at the time of the incident and expressed that such behavior should not occur in the facility.
Improper Storage of Ice Scoop in Kitchen
Penalty
Summary
The facility failed to ensure the ice scoop used for the kitchen's ice machine was stored in a clean and sanitary manner, as required by the facility's policy. During an observation and interview with the Dietary Services Supervisor (DSS), the ice scoop was found resting inside an uncovered blue container near the ice machine. The DSS confirmed that the ice scoop should always be stored in a clean, covered container to prevent contamination. This oversight posed a potential risk for contamination of ice, which could lead to foodborne illness and negatively impact the health and safety of all 96 residents who received food and beverages from the kitchen. Further interviews and record reviews revealed that the facility's policy, titled 'Ice Machines and Ice Storage Chest' dated January 2012, was not followed. The Maintenance Director (MD-1) acknowledged that the ice scoop should have been stored in a covered container, as per the policy. The Infection Control Prevention Nurse (ICP Nurse) also confirmed that the ice scoop placement did not follow protocol, emphasizing that ice is considered a food item and must be protected with a lid to prevent contamination. The failure to adhere to these protocols was acknowledged by the staff involved.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control policies for several residents, leading to potential cross-contamination and infection risks. Resident 44's Central Venous Catheter (CVC) dressing was not changed according to the facility's policy, which requires a change every seven days or when soiled. The dressing was last changed on January 1, 2025, but should have been changed by January 8, 2025. Additionally, Resident 44's intravenous (IV) tubing was not dated as required by the facility's policy, which mandates labeling with the date, time, and initials upon assembly. Resident 33's oxygen tubing was not changed for 17 days, contrary to the facility's policy of changing it every seven days. Similarly, Resident 65's oxygen tubing was not labeled with the date, violating the same policy. These oversights in labeling and changing medical equipment increase the risk of infection among residents. Furthermore, staff members failed to perform proper hand hygiene during care activities. LVN 1 did not wash hands after touching Resident 5 and before administering medication, while CNA 1 did not change gloves or perform hand hygiene between assisting two residents with breakfast. These actions contravene the facility's hand hygiene policy, which requires handwashing before and after resident contact and before handling medications.
Failure to Complete Timely SCSA for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) for a resident within the required 14-day period after the resident was admitted to hospice care. This oversight was identified during a review of the resident's clinical records and interviews with the Minimum Data Set (MDS) Nurse. The resident, who was admitted with diagnoses including cerebrovascular disease and atherosclerosis heart disease, was enrolled in hospice care on May 24, 2024. However, the SCSA, which should have been completed by June 6, 2024, was not conducted, resulting in a delay of over six months. The failure to complete the SCSA meant that the resident's care plan was not updated to reflect her current status, potentially delaying the identification and implementation of necessary care and support. The facility's policy, which aligns with the OBRA regulations and the CMS RAI manual, mandates a comprehensive assessment when a significant change in a resident's condition occurs, such as enrollment in hospice care. The MDS Nurse acknowledged that the facility did not adhere to this policy, which is crucial for ensuring a coordinated plan of care between the hospice and the nursing home.
Inaccurate MDS Assessments for Insulin and Antibiotic Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to potential inaccuracies in identifying their care and support needs. Resident 9, who was admitted with Type 2 diabetes mellitus and required long-term insulin use, had insulin injections that were not coded on the MDS assessment. Despite receiving insulin injections on six days within the seven-day look-back period, the MDS assessment inaccurately indicated that no insulin was administered. This discrepancy was acknowledged by the MDS Nurse 2 during a review of the Medication Administration Record (MAR) and the MDS Section N - Medications. Similarly, Resident 19, who was admitted with complications related to an orthopedic implant and osteomyelitis, was on a prescribed antibiotic regimen. The MDS assessment for Resident 19 failed to reflect the administration of antibiotics, despite the MAR indicating daily antibiotic administration throughout December. The MDS Nurse 1 acknowledged the error during a review of the MAR and MDS Section N, admitting it was a mistake. The Director of Nursing (DON) confirmed that the facility's policy and procedure for certifying the accuracy of resident assessments were not followed in both cases. The CMS RAI manual guidelines, which require accurate recording of medication administration during the look-back period, were also not adhered to. These failures in accurately coding the MDS assessments for both residents were identified through interviews and record reviews with the MDS nurses and the DON.
Failure to Communicate Speech Therapy Order for Hospice Resident
Penalty
Summary
The facility failed to ensure a physician's order for a Speech Therapy (ST) evaluation was carried out timely for a resident receiving hospice care. The resident, who was admitted with diagnoses including cerebral atherosclerosis, unspecified dementia, and was receiving palliative care, had a severe cognitive impairment as indicated by a BIMS score of 6. A Nutrition/Dietary Note dated November 22, 2024, recommended an ST evaluation due to the resident's difficulty chewing, which was subsequently ordered by the physician on November 23, 2024. However, the order was not communicated to the hospice provider, and there was no documentation of the ST evaluation being conducted. During interviews and record reviews, the Director of Nursing (DON) confirmed the lack of documentation for the ST evaluation and identified that a Registered Nurse from the registry failed to communicate the order with the facility or the hospice provider. The facility's policy and procedure for hospice care, which requires coordination with the hospice provider and documentation of communication, was not followed. This oversight had the potential to place the resident at risk for aspiration, weight loss, and further nutritional decline.
Failure to Implement Restorative Nursing Program Recommendations
Penalty
Summary
The facility failed to implement the Restorative Nursing Program (RNP) recommendations for two residents, leading to a deficiency in providing necessary care and services for maintaining or improving their activities of daily living. Resident 44, who was admitted with muscle weakness and difficulty walking, did not receive the recommended ambulation with a front wheel walker as suggested by the Physical Therapist (PT). The Director of Nursing (DON) and the Director of Rehabilitation (DOR) were unaware of the PT's recommendation, indicating a lack of communication between the nursing and rehabilitation departments. Similarly, Resident 54, who was admitted with muscle contracture and weakness, did not receive the recommended Range of Motion (ROM) exercises as advised by both the PT and Occupational Therapist (OT). The DON and DOR confirmed the absence of documented evidence showing the implementation of these recommendations. The lack of communication between the nursing and rehabilitation departments was again highlighted as the reason for this oversight. The facility's policy on Restorative Nursing Services, which emphasizes the need for individualized and resident-centered care, was not followed. The policy outlines that residents should receive restorative nursing care to promote optimal safety and independence, and that such care should be documented in the resident's plan of care. The failure to adhere to this policy resulted in a delay in the continuity of care for the residents involved.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident, identified as Resident 33, who was admitted with diagnoses including dementia, retropharyngeal and parapharyngeal abscess, and shortness of breath. During an observation, Resident 33 was found using a nasal cannula attached to an oxygen concentrator set at 2 liters per minute, without a corresponding physician's order documented in their clinical record. This oversight was confirmed during an interview and record review with the Director of Nursing (DON), who acknowledged the absence of the necessary order. The facility's policy and procedure for oxygen administration, which requires verification of a physician's order before administering oxygen, was not adhered to in this instance. The DON reviewed the policy, which was last revised in October 2010, and confirmed that it was not followed. This failure to comply with the established protocol had the potential to expose Resident 33 to risks associated with unmonitored oxygen therapy, such as oxygen toxicity.
Expired Nursing License Overlooked
Penalty
Summary
The facility failed to ensure that their professional staff maintained an active and current nursing license, as evidenced by a Licensed Vocational Nurse (LVN) working with an expired license. The LVN worked from a specified date through another specified date with a delinquent license, which was not renewed within the required timeframe. During an interview and record review, the Director of Nursing (DON) acknowledged that it was her responsibility to verify the nurses' licenses. Although the DON checked the LVN's license the previous month and found it active, she did not verify the expiration date. The facility's job description for the LVN position required current nursing licensure in the state of California, which was not adhered to, resulting in the LVN working without a valid license during the specified period.
Failure to Adhere to Blood Glucose Monitoring Schedule
Penalty
Summary
The facility failed to implement its policy for blood glucose monitoring for a resident with type 2 diabetes mellitus, which potentially led to a change in the resident's condition and subsequent transfer to a general acute hospital for evaluation and treatment. The resident, who was admitted with a diagnosis of type 2 diabetes and had moderate cognitive impairment, was supposed to have blood sugar checks conducted before meals and at bedtime as per physician's orders. However, a review of the resident's Blood Sugar Summary indicated that the blood sugar check was conducted later than the scheduled time, specifically at 1:38 p.m., instead of before meals around 11:30 a.m. During an interview, the Maternal Data Set Assistant Coordinator confirmed the delay in conducting the blood sugar check and acknowledged that the facility did not adhere to the physician's orders. The facility's policy and procedure for glucose monitoring, dated December 2015, stated that the management of individuals with diabetes mellitus should follow relevant protocols and guidelines, and the physician would order the frequency of glucose monitoring. This failure to adhere to the scheduled blood glucose monitoring had the potential to jeopardize the health and well-being of the medically compromised resident.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to adhere to its policy and procedure for activities of daily living (ADL) by not ensuring proper grooming and personal hygiene for a resident. The deficiency was identified during an observation of a resident who had notably long and unclean fingernails. This resident, who was admitted with a diagnosis of unspecified dementia and had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, required partial/moderate assistance with personal hygiene according to their MDS Section G assessment. During an observation and interview, both the Administrator and the Resident Assessment Coordinator acknowledged the resident's unclean and untrimmed fingernails. The Administrator stated that it was the responsibility of the CNAs to clean or trim the resident's fingernails. The facility's policy, dated March 2018, indicated that residents unable to perform ADLs independently should receive necessary services to maintain grooming and personal hygiene. The failure to maintain the resident's fingernails put the resident at risk for infection.
Failure to Follow Restraint Policy
Penalty
Summary
The facility failed to follow its policy and procedure for restraints when a Certified Nursing Assistant (CNA) wrapped a resident's waist and legs in linen sheets. This incident involved a resident with severe cognitive impairment, dementia, an unspecified fracture of the right lower leg, and schizoaffective disorder. The resident was admitted to the facility with a care plan that required all care to be delivered by licensed nursing staff and adjunct professional medical personnel. The resident's care plan also indicated a risk for decline in psychosocial well-being due to involuntary seclusion and required staff education on the use of restraints and types of restraints. On the day of the incident, the resident was observed sitting in a Geri-chair in the activities room, smiling and grabbing at the upper part of her pants. The resident was unable to recall the incident. During a telephone interview, the CNA admitted to placing the sheet around the resident to prevent her from digging into her pants and smearing feces, based on information told to her by someone else. The CNA acknowledged that this was not the right measure. Another CNA reported the incident to an LVN, who conducted a body assessment and found no markings on the resident's skin. The LVN then informed the Director of Nursing (DON). The facility's policy and procedure on the use of restraints, revised in April 2017, stated that restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints should never be used for discipline or staff convenience. The policy defined physical restraints and specified that practices preventing resident mobility, such as tucking sheets tightly, are considered restraints and are not permitted. The DON confirmed that the policy and procedure were not followed in this case.
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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 Loma Linda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loma Linda Post Acute | 0.3 mi | ★★★★★ | 0 | 0 |
| Asistencia Villa Healthcare Center | 1.1 mi | ★★★★★ | 18 | 0 |
| Totally Kids Rehabilitation Hospital - D/p Snf | 1.7 mi | ★★★★★ | 10 | 0 |
| The Canyons Post-acute | 2.3 mi | ★★★★★ | 8 | 0 |
| Brookside Healthcare Center | 2.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.