Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Kindred Hospital Brea D/p Snf during CMS and state inspections, most recent first.
Improper Head-of-Bed Positioning During GT Feeding: A resident receiving GT feeding was observed lying in bed with the HOB at 20 degrees while the feeding was actively infusing, despite the care plan and facility P&P directing HOB elevation to 30 to 45 degrees or upright positioning during and after tube feeding. An LVN confirmed the resident should have been at 45 degrees and verified the lower HOB setting during the feeding; the Administrator and DON acknowledged the findings.
A resident had discontinued respiratory orders that were not signed and dated by the physician. The record showed an order to discontinue the vent and downsize the trach, as well as a verbal order to titrate O2 to maintain saturation, but neither document showed physician signature. The Administrator stated the facility did not have a system for physicians to sign discontinued orders, and the Administrator and DON acknowledged the findings.
Failure to Document Non-Pharmacological Interventions and Behavior Monitoring for Psychotropic Medications Multiple residents receiving psychotropic meds had missing documentation showing non-pharmacological interventions were attempted before routine or PRN administration. Records also lacked required behavior monitoring and, for one resident, sleep monitoring tied to trazodone use. Staff interviews confirmed the documentation was not available for review, including for antipsychotic, antianxiety, antidepressant, and mood-stabilizing meds ordered for behaviors such as anxiety, restlessness, mood swings, sad mood, and disruptive behavior.
Medication administration, accounting, and destruction records were inaccurate. A resident’s Ativan record did not match the MAR and physician orders, and the resident’s midodrine was documented as given despite SBP being above the hold parameter. Another resident’s midodrine was also given outside ordered parameters. The facility’s drug destruction logs lacked required RN and witness signatures, and a controlled med record for another resident did not match the remaining supply count.
Improper Storage and Labeling of Medications and Biologicals: Staff left a medication destruction container unsecured with intact meds still inside, stored expired compounded Vancomycin in a med room refrigerator, left a med cart unlocked and unattended, and kept an open bottle of glucometer test strips without open or discard dates. A bottle of Pro-Stat had a damaged pharmacy label and residue, and a Triad wound dressing was left at a resident bedside without a label; one resident had no order for Triad and another had an order for barrier cream.
Kitchen sanitation and food service practices were deficient when a reach-in refrigerator lacked a thermometer and had dirty racks, expired and undated food items were found in storage, sanitizer was kept near food, and expired Ensure was stored in a resident refrigerator. The dishwashing log was incomplete, beard restraints were worn improperly by kitchen staff, steam table foods were held at low temperatures, and staff could not identify the emergency food storage location or find a can opener for canned emergency supplies.
The facility failed to maintain an accurate infection control surveillance program by limiting surveillance to residents on antimicrobials and excluding residents with signs and symptoms of infection who were not prescribed those medications. Staff also failed to follow hand hygiene practices when an EVS staff member changed a trash liner in a room under C. diff contact isolation and when an RN moved from GT medication administration to a SC injection without changing gloves or performing hand hygiene.
Failure to Document Vaccine Education and VIS for Influenza and Pneumococcal Immunizations: The facility did not document that influenza and pneumococcal vaccine education, including risks, benefits, potential side effects, and updated VIS, was reviewed with residents and/or representatives for multiple residents. Records showed one resident received pneumococcal vaccine without evidence of updated VIS or education, another resident lacked documentation of vaccine status and consent details, one resident received influenza vaccine without documented education, and two residents with no capacity had vaccine refusals or administration without documented representative education.
COVID-19 Vaccine Education and Documentation Not Completed: The facility failed to document that residents or their representatives were educated on the risks, benefits, and potential side effects of the updated COVID-19 vaccine before vaccination or refusal for several residents. Records showed one cognitively intact resident received the vaccine and others with no decision-making capacity had representatives decline it, but the VIS/consent forms did not show the required education. The IP/DSD stated she provided the consent form, but could not produce documentation showing the updated VIS information was reviewed.
A resident was transferred to an acute care hospital and elected a seven-day bed hold under the facility’s SAU bed-hold policy. Hospital notes documented that the resident’s condition stabilized and improved, and hospital staff informed the facility that the resident was ready to return. However, based on a phone call in which a hospital discharge coordinator reportedly said the resident would not be returning "any time soon" and would remain hospitalized a few more days, the Administrator cancelled the bed hold before it expired, discharged the resident from the room, and reassigned the room to another resident without further clarification. The facility later stated that only a limited number of unit rooms were covered by the resident’s insurance and that the resident was placed on a waiting list for a covered room, while a contracts official confirmed the room could have been held longer if the resident was expected to return.
Two residents were transferred or discharged without receiving required written notices detailing reasons for the move, appeal rights, and bed-hold information. One resident with decision-making capacity was discharged to an assisted living facility; staff documented only a telephone notification to the representative, with no evidence that a written notice was provided or mailed. Another resident on the SAU was transferred to an acute care hospital with a bed-hold election documented, but the family member later reported not receiving the written transfer/discharge notice or its contents. Nursing and medical records staff each believed the other was responsible for mailing the notices, resulting in the residents’ representatives not obtaining the mandated written information.
A resident who was cognitively intact and able to make health care decisions had trazodone ordered for depression related to difficulty falling asleep. The record showed the medication was changed from PRN to routine at bedtime, but the chart did not contain documented informed consent from the resident or responsible party for the change, and an RN confirmed the missing documentation during review.
Advance Directive Missing From Medical Record: A resident who had the capacity to make healthcare decisions stated she had an advance directive, and a family member later showed a copy on a phone. However, the medical record and POLST did not contain the advance directive, and staff stated the admission process included asking the resident or responsible party about one.
A facility failed to develop resident-centered care plan problems for two residents receiving insulin. One resident had orders for basal and sliding-scale insulin, and another had an order for insulin every 6 hours; however, the care plans did not include a problem addressing insulin use. RN verified the omission during record review, and the DON acknowledged the findings.
Failure to Document Individualized Activities: A resident with memory problems, no capacity for health care decisions, and dependence on staff for ADLs had documented preferences for music, TV, and other sensory activities, with a care plan calling for regular one-to-one in-room visits. However, the resident was observed lying awake in bed and not engaged in activities, and the activity record had no entries showing that meaningful activities were provided. The Activity Director said music, TV, and one-to-one sensory stimulation were offered, but could not produce documentation, and the DON acknowledged the finding.
A resident with Stage IV pressure injuries to the sacrum and hip was cared for on a special pressure-reducing mattress that had an error code and flashing light, and the resident reported the mattress was not inflating or deflating. Staff observed the issue but did not identify the code, and there was no MD order for the special mattress despite it being listed in the care plan.
Incomplete RNA Services and ROM Support for a Resident With Limited Mobility: A resident with severe cognitive impairment, bilateral extremity impairment, and hand contractures had a care plan for Hoyer lift transfers, PROM to both lower extremities, and PRAFO boot use. The PT discharge instructions and physician order did not clearly specify the frequency of RNA services, how long the PRAFO boots should be worn, or skin check requirements. RNA staff reported providing the services, but could not explain PRAFO duration or skin checks, and the DSD/IP acknowledged the missing clarification and documentation.
A facility failed to provide appropriate pain management for two residents. One resident's admission pain assessment was incomplete, with no documented pain history, prior effective treatments, or pain characteristics, and PRN opioid pain medication was given at times outside the ordered pain range. Both residents received PRN and routine pain medications without documentation that non-pharmacological interventions were attempted first, and staff confirmed the missing documentation during record review.
Competency Failures in GT Medication Administration and Vaccine VIS Education: An LVN administered crushed meds and vitamins/minerals undiluted through a resident's GT, despite facility P&P stating they should be reconstituted with water before administration. The facility also failed to ensure the IP/DSD knew how to provide the current VIS for influenza, pneumococcal, and COVID-19 vaccines; the consent form listed vaccine types but did not show the risks, benefits, and potential side effects, and the IP/DSD stated she did not provide the updated VIS to residents or their representatives.
Failure to Follow Pharmacist MRR Recommendations for Midodrine Administration: The facility did not act on the consultant pharmacist’s MRR recommendation to remind staff about administering and holding midodrine within ordered parameters. A resident’s midodrine was documented as given when SBP was above the hold limit, and the same issue continued for two residents with multiple MAR entries showing midodrine administered when SBP exceeded the ordered parameter. The DSD said she did not review the MRR reports or provide staff training based on the findings, and the DON said he did not see the recommendation in the report.
Medication error rate exceeded the required threshold, with an observed rate of 32%. During med pass observations, an LVN and an RN each administered crushed meds via GT and left residue in medication pouches and cups for multiple medications, including an opioid/APAP, anxiolytic, antihistamine, vitamins, diuretic, and bowel meds.
Inaccurate pain and wound documentation: A resident’s TAR did not reflect the highest pain level for multiple shifts even though the MAR showed PRN hydrocodone-acetaminophen was given for higher pain scores, and the DON confirmed the shift pain documentation was incomplete. Another resident’s left lateral head pressure injury was documented as a DTI on the wound assessment after it had already been staged as a Stage 4, even though the MDS Coordinator and an LVN stated a wound remains a Stage 4 until healed.
Kitchen sink equipment was not maintained in working condition. During a kitchen tour, Sink 1 was found not working and Sink 2 had missing faucet knobs, and the Dietary Mgr verified the findings. Staff reported work orders had been open for both sinks since 1/6/26, but the faucets had not been replaced because approval was still pending.
A respiratory therapist failed to promptly assess and call for help for a resident with severe cognitive impairment who was found unresponsive and jaundiced with an alarming pulse oximeter. The RT spent several minutes troubleshooting equipment and performing suctioning without first checking vital signs or immediately activating emergency response, and did not document the interventions as required by facility policy.
A resident with impaired cognitive skills underwent bedside debridement procedures for scrotal and perineal/perianal wounds without the required physician orders and informed consents, and wound assessments were not completed or documented after the procedures, contrary to facility policy. Staff interviews confirmed the absence of necessary documentation and consents.
The facility did not ensure proper pressure ulcer care for three residents, including failing to notify the physician when a wound worsened and not setting LAL mattresses according to residents' weights. Staff did not document required notifications or adjust support surfaces as per policy, leading to deficiencies in wound management.
The facility failed to attempt least restrictive alternatives before using bed rails for several residents, as required by its policy. Observations and interviews revealed that residents were found with elevated side rails without documented evidence of alternative measures being tried first. Staff confirmed the use of side rails and acknowledged the lack of documentation for alternative measures.
The facility's kitchen was found to have multiple sanitation deficiencies, including a dirty ice machine, microwave, and kitchen hood. Kitchen utensils and equipment were in poor condition, with several items being dirty, discolored, or damaged. Expired sanitizer test strips and food items were also found, posing a risk of foodborne illnesses. These issues were acknowledged by the facility's staff during the survey.
The facility failed to complete entrapment assessments and document bed rail measurements for several residents, potentially leading to serious injury or death. Observations and interviews revealed that necessary assessments for Zones 5 and 6 were not documented, and responsibility for these assessments was unclear among staff. The facility's policies require such assessments, but they were not followed, indicating a systemic issue in safety protocol adherence.
The facility failed to ensure proper care for residents with gastrostomy tubes (GT), as two residents had unlabeled feeding bottles and irrigation equipment, and two other residents did not have their GT dressings changed daily as ordered. These deficiencies were confirmed by staff during observations and interviews.
A facility failed to document necessary measurements and develop a care plan for a resident's PICC line, as required by their policies. The lack of documentation and planning was confirmed through medical record reviews and staff interviews, highlighting a deficiency in maintaining intravenous access care.
The facility failed to provide appropriate respiratory care, as several residents' nasal cannulas and nebulizer equipment were not labeled or stored properly. Additionally, the facility did not follow maintenance guidelines for a BiPAP machine and lacked necessary signage for oxygen usage. These deficiencies were acknowledged by staff, indicating systemic issues in maintaining respiratory care protocols.
The facility did not follow the pureed recipe for steamed green beans for two residents on a pureed diet. The preparation deviated from the specified recipe, resulting in a runny consistency instead of the required smooth, pudding-like texture. RD 2 confirmed the recipe was not followed, which could alter the nutritional content of the meal.
The facility failed to ensure proper storage and labeling of medications, including missing temperature logs, improper disposal of an empty bottle, and medication residue on a cart. A resident's sodium chloride irrigation bottle was found opened and undated, which was confirmed by staff and acknowledged by the DON.
A resident with neuromuscular dysfunction of the urinary bladder had an indwelling urinary catheter, which was not placed inside the dignity bag as required by the physician's order. During an observation, the catheter bag was found outside the dignity bag, compromising the resident's privacy. Staff interviews confirmed the oversight, highlighting a failure to adhere to protocols ensuring resident dignity.
The facility failed to properly store garbage in four of nine dumpsters, as observed during a survey. The facility's waste management policy requires dumpster lids to be closed, and the FDA Food Code mandates tight-fitting lids to prevent pest attraction. During an observation, four dumpsters had lids partially propped open by garbage, which the EVS Manager confirmed as an infection control issue.
A resident experienced verbal abuse from a CNA, who made derogatory comments about the resident's personal life and broke confidentiality. The incident was not reported in a timely manner, violating the facility's policies and procedures. The Director of Nursing was unaware of the incident until a complaint was filed, and there was no documentation or care plan addressing the altercation.
A resident developed a new skin discoloration on her wrist, but the facility failed to notify the physician, create a care plan, or monitor the condition. Despite the resident being on anticoagulant medication and the discoloration being reported by a CNA, there was no documentation or follow-up by the staff, indicating a failure to adhere to the facility's policy on managing changes in a resident's condition.
Improper Head-of-Bed Positioning During GT Feeding
Penalty
Summary
The facility failed to provide necessary GT care and services for one of four sampled residents, Resident 1. The deficiency involved enteral feeding administration and positioning. The facility’s policy for administration of enteral nutrition, dated 1/2026, directed staff to position the resident with the head of the bed elevated at least 30 degrees or upright in a chair to prevent aspiration. Resident 1’s care plan included interventions to elevate the head of the bed 30 to 45 degrees during tube feeding and to maintain that elevation for 30 to 40 minutes after feeding stopped, and another care plan problem for GI bleeding and GERD directed that the resident be positioned upright while tube feeding was running and for 30 to 45 minutes afterward. During observations on 5/29/26, Resident 1 was seen lying in bed with the head of the bed at 20 degrees at 0929 hours and again at 1025 hours. At 1306 hours, LVN 1 stated the head of the bed should be at 45 degrees because Resident 1 was receiving GT feeding, then verified the head of the bed was still at 20 degrees while the GT feeding was actively infusing. At 1700 hours, the Administrator and DON were interviewed and acknowledged the findings.
Unsigned Discontinued Respiratory Orders
Penalty
Summary
Resident 4 had discontinued respiratory orders that were not signed and dated by the physician. Medical record review showed a new physician order on 3/10/26 to discontinue the vent and downsize the trach to an uncuffed Portex 6, but the Clinical Note Summary did not show the discontinued order was signed and dated by the physician. The record also showed a verbal physician order on 3/20/26 to titrate oxygen to maintain oxygen saturation, and the document did not show the physician signed the order. The facility's P&P titled Readmission, Handwritten Orders, and Written Transfer Orders directed staff to enter orders into the EMR, where the physician electronically signs the order. During interviews on 5/29/26, the Administrator stated the facility did not have a system for physicians to sign discontinued orders. The Administrator and DON were informed of and acknowledged the findings.
Failure to Document Non-Pharmacological Interventions and Behavior Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that five sampled residents receiving psychotropic medications were appropriately monitored and that non-pharmacological interventions were documented before medication administration. The deficiency involved Residents 1, 7, 13, 22, and 40, and the record review and staff interviews showed missing documentation related to behavior monitoring, sleep monitoring, and attempts at non-pharmacological interventions for both routine and PRN psychotropic medications. For Resident 7, the record showed orders for Seroquel, divalproex, and PRN Ativan for depressive episodes, mood swings, and anxiety with restlessness. The MAR showed Ativan was administered 35 times in January 2026, but non-pharmacological interventions were documented for only four doses, with no documentation for the remaining 31 doses. The record also did not show non-pharmacological interventions for the routine Seroquel and divalproex. The record further did not have readily available monthly behavior summaries, and the SSD stated behavior monitoring was completed only quarterly, aligned with the MDS schedule rather than monthly. For Resident 13, the record showed orders for clonazepam for anxiety and fluoxetine for depression. The record did not show non-pharmacological interventions were implemented for the routine psychotropic medications. The resident’s social services note contained behavior tallies for September, October, and November 2025, but no more recent monthly behavior monitoring was documented after November 2025. For Resident 1, the record showed trazodone ordered for difficulty falling asleep and sertraline for depression with constant worry about health, but there was no documentation that hours of sleep were monitored for trazodone and no documentation of non-pharmacological interventions for sertraline when the resident had sad mood. For Resident 22, hydroxyzine PRN was ordered and administered for anxiety manifested by physical restlessness, but the record did not show non-pharmacological interventions before administration. For Resident 40, quetiapine was ordered for yelling and crying disruptive behavior, behavior monitoring was ordered, and the medication was administered, but the record did not show documented non-pharmacological interventions attempted before administration.
Medication Administration, Accounting, and Destruction Records Were Inaccurate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, properly accounted for, and destroyed according to pharmaceutical protocols. Review of facility policy showed the MAR was to reflect the most recent medication order and the correct dose was to be verified before administration. The deficiencies involved controlled medications, blood pressure medications with hold parameters, and medication destruction records. For Resident 7, the controlled medication record for Ativan did not match the MAR and physician orders. One 0.5 mg tablet was removed from the medication supply at a time when the prior order had already been discontinued and before the new 1 mg PRN order was active, and the MAR did not document that removal as administered. Later, the MAR documented 1 mg as administered when only one 0.5 mg tablet had been removed. Resident 7 also had a midodrine order for 5 mg via GT every 8 hours with instructions to hold for SBP greater than 130, yet the MAR documented doses as given when the recorded SBP values were above the hold parameter on multiple occasions. Resident 13 had a midodrine order for 10 mg via GT every 12 hours with instructions to hold for SBP greater than 130, but the MAR documented administration when the SBP was 139. In addition, the facility’s drug destruction logs showed multiple expired or discontinued medications destroyed without the required witness signature, and one entry lacked both the RN and witness signatures. For Resident 46, a controlled medication log for hydrocodone-acetaminophen did not match the medication supply count, as one tablet had been removed but not signed out in the controlled drug record.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly stored and labeled in Medication Room A, Medication Carts A and B, and at the bedside of two residents. During an inspection of Medication Room A, the medication destruction incinerator container was observed unsecured on the floor, with the lid able to slide fully back and multiple medications still intact and removable inside, including unopened vials, liquid medications, tablets, capsules, a bag of 0.9% Sodium Chloride attached to a vial of powder, and sealed suppositories. The Director of Nursing stated the medications placed in the incinerator should be destroyed so they were not usable. In the refrigerator in Medication Room A, two bottles of compounded Vancomycin were found past their labeled use dates, with one showing an expiration date of 1/1/26 and the other labeled to discard by 1/26/26. In Medication Cart B, an RN left the cart unlocked and unattended in the hallway while walking away to a resident room, with EVS staff nearby. The same cart also contained an open bottle of glucometer test strips with blank open and discard date fields, and the DSD stated the strips should be dated when opened and discarded 180 days later. Medication Cart A contained a bottle of Pro-Stat with a torn, stained, sticky pharmacy label and sticky residue on the bottle neck. In a resident room, a Triad hydrophilic wound dressing was observed left at the bedside near one resident's bed without a label. One resident had no medical decision-making capacity and no order for Triad, while the other resident had an order for house barrier cream to the perineal area every shift; staff stated the facility used Triad as a house barrier cream and that it should not have been left at the bedside.
Kitchen sanitation, food storage, and temperature control failures
Penalty
Summary
The facility failed to maintain sanitation in the kitchen and related food storage areas. During a tour of the kitchen, a red bucket containing sanitizing solution was observed near food items on a counter, a reach-in refrigerator was found without a thermometer and with brown discoloration on two racks, and a pack of gloves and two packs of aluminum sheets were stored inside that refrigerator. On the kitchen counter near the dry food storage room, one bag of corn meal had an expiration date of 12/25 and one bag of tempura shrimp had no expiration date. Inside a refrigerator across from the stove, a bag of tortillas was observed with a use-by date of 12/18/25. The dishwashing area was also found to have deficiencies. The three-compartment manual dishwashing sink was not working, and the food preparation sink was missing faucet knobs and was not working. During a machine dishwashing observation, the facility’s temperature log for the dishwasher was not completed for 1/27 and 1/28/26, despite the facility procedure requiring temperature checks and documentation before washing dishware. Three male kitchen staff were observed with beard restraints placed underneath their moustaches, not fully covering their facial hair. Food service temperature control was also deficient. During trayline observation, two steam table compartments were not producing steam, the water under the pans was not hot to the touch, and the chopped beef measured 90 degrees Fahrenheit while the mashed potatoes measured 101 degrees Fahrenheit. In addition, two bottles of Ensure in the residents’ refrigerator were expired, two staff did not know the location of the emergency food storage, and the emergency food storage in the dry food area did not have a can opener readily available for canned items. The closet used for enteral feedings and nutritional supplements also did not have a thermometer in place.
Infection Control Surveillance and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an accurate infection control surveillance program for November and December 2025 and January 2026. Review of the Infection Prevention and Control Surveillance Log showed surveillance was conducted only for residents who exhibited signs and symptoms of infection and were prescribed antimicrobial medications. The infection preventionist stated that residents with signs and symptoms of infection who were not prescribed antimicrobial medications were not included in the surveillance log, and acknowledged that they should have been included. The facility also failed to ensure hand hygiene was performed after changing the trash liner in the room of a resident on contact isolation for C. diff. The resident had a physician order for contact isolation for C. diff, and contact isolation signage was posted outside the room. An EVS staff member was observed placing a new trash bag into the trash receptacle inside the resident’s room, then leaving the room and using ABHR before going to another resident’s room. The staff member stated she did not need to wash her hands because the trash had already been emptied by someone else. The infection preventionist stated the trash bin was not a clean surface and that ABHR was not appropriate for C. diff. The facility further failed to ensure proper hand hygiene between medication administrations for another resident. During observation, an RN performed hand hygiene and donned gloves before administering GT medications, but after completing the GT medications, the RN administered a SC injection without changing gloves or performing hand hygiene. The RN verified that she failed to change her gloves and perform hand hygiene between the GT and SC medication administrations, and the infection preventionist stated staff should remove gloves, perform hand hygiene, and apply new gloves when moving from GT medication administration to SC injection administration.
Failure to Document Vaccine Education and VIS for Influenza and Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that education regarding the risks, benefits, and potential side effects of influenza and pneumococcal vaccinations was reviewed with residents and/or their representatives for five of six residents reviewed for immunization. The facility policy stated that both influenza and pneumococcal immunizations were offered unless medically contraindicated, refused, or already received, and that the information and education provided regarding the benefits and risks of immunization were to be documented in the medical record. For one resident who had capacity to understand and make healthcare decisions and was cognitively intact, the record showed pneumococcal vaccination was given in the facility, but the documentation did not show that the updated VIS was provided before administration or that the risks, benefits, and potential side effects were explained. For another resident with no capacity to make healthcare decisions, the record did not show whether influenza and pneumococcal vaccines were actually received, and the consent form did not show the date the VIS was provided or that the updated influenza and pneumococcal VIS were given, or that the risks, benefits, and potential side effects were explained to the resident or representative. For a resident with severe cognitive impairment and no capacity to make healthcare decisions, the record showed influenza vaccine was administered, but the consent form did not show that the updated influenza VIS was provided or that the risks, benefits, and potential side effects were explained to the resident or representative before vaccination. For another resident with no capacity and memory problems who was dependent on staff for activities of daily living, the record showed the influenza and pneumococcal vaccines were declined by the representative, but there was no documentation that the representative received education on the risks, benefits, and potential side effects. For a fifth resident with no capacity, the record showed the representative declined influenza vaccination and consented to pneumococcal vaccination, which was then administered, but the documentation did not show that the resident or representative received the updated VIS or education on the risks, benefits, and potential side effects of either vaccine.
COVID-19 Vaccine Education and Documentation Not Completed
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided education on the risks, benefits, and potential side effects of the COVID-19 vaccination before the vaccine was administered or declined for five residents reviewed for immunization. The facility’s COVID-19 Vaccination policy stated that the resident medical record would include documentation that the resident and/or representative was provided education regarding the benefits and potential side effects of immunization, and whether the resident received or did not receive the immunization due to medical contraindication or refusal. Resident 1 had capacity to understand and make healthcare decisions and was cognitively intact, and the medical record showed the resident received the Spikevax COVID-19 vaccine. The Vaccine VIS Acknowledgement and Consent form indicated the resident wanted the vaccine, but it did not show that education on the risks, benefits, and potential side effects was provided. Resident 3 had no capacity to make healthcare decisions, and the record showed the resident received the COVID-19 vaccine; however, the Vaccine VIS Acknowledgement and Consent form did not show that the resident or representative received education on the risks, benefits, and potential side effects before vaccination. Residents 8, 18, and 27 all had no capacity to make healthcare decisions, and each had a representative decline the COVID-19 vaccine. Their Vaccine VIS Acknowledgement and Consent forms did not show that the resident or representative was provided education on the risks, benefits, and potential side effects before the refusal. During interview and concurrent record review, the IP/DSD stated she provided the Vaccine VIS Acknowledgement and Consent form before vaccination, but acknowledged the form did not contain updated vaccine information and did not include the risks, benefits, and potential side effects of the updated COVID-19 vaccine. The IP/DSD was unable to produce the form she said was provided, and the DON was informed and acknowledged the findings.
Failure to Follow Bed-Hold Policy Resulting in Loss of Resident’s Room
Penalty
Summary
The deficiency involves the facility’s failure to follow its bed-hold policy and ensure an appropriate transfer/discharge process for a resident who was hospitalized. The facility’s policy for the Subacute Unit (SAU) required that at the time of transfer or discharge, the resident and representative receive written notice of the bed-hold policy, including the duration of the bed hold and readmission criteria, and that residents whose hospitalization exceeds the bed-hold period be allowed to return upon the first availability of a semi-private bed if they still require SAU services and are Medicaid-eligible. The policy also required that if a resident transferred with an expectation of return could not come back, the facility must provide written notice of transfer/discharge, including reasons for the move, effective date, new location, appeal rights, and contact information for the state LTC ombudsman and protection and advocacy agencies, and send a copy to the ombudsman. The resident was admitted to the facility and later transferred to an acute care hospital, with a Notice of Transfer/Discharge indicating the transfer was necessary for the resident’s welfare and that the resident’s needs could not be met in the facility. A SAU Form–Notice of Bedhold documented that the resident left for hospitalization and elected to hold the bed for a specified seven-day period. Hospital progress notes showed that within that period the resident’s condition stabilized and improved, and that the resident could begin planning to return to the facility and remained stable for return. The hospital case manager reported that hospital staff informed the facility that the resident was ready to return, but the facility stated there was no available bed on the unit where the resident had previously resided. The Administrator reported that, based on a telephone conversation with a hospital discharge coordinator indicating the resident would not be returning to the facility “any time soon” and would be in the hospital a few more days, he cancelled the resident’s bed hold, discharged the resident from the room, and reassigned the room to another resident before the end of the elected bed-hold period. The Administrator did not further clarify with hospital staff what was meant by the statement that the resident would not be returning “any time soon” and did not obtain a more specific anticipated return date. The Administrator also stated that only 14 rooms on the unit were covered by the resident’s insurance and that the resident was placed on a waiting list for a covered room. A Contracts Unit Chief later confirmed that the facility could have held the resident’s room for two weeks from the date of transfer if the resident was expected to return and acknowledged that the Administrator should not have cancelled the bed hold.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer/discharge, including appeal rights and bed-hold information, to residents or their representatives. Facility policy titled “Transfer Discharge Bed-Hold Procedure” required that the patient and, if known, the family member, surrogate, or legal representative be notified at least 30 days prior to transfer when applicable, and that the written notice include the reason for transfer/discharge, effective date, new location, appeal rights, and contact information for the state LTC ombudsman and protection and advocacy agencies. Surveyors found that for two of three sampled residents reviewed for transfer and discharge, these written requirements were not met. For one resident (Resident 39), the medical record showed admission in October 2025 and a physician’s order dated 11/11/25 for discharge to an assisted living facility. The H&P documented that this resident had capacity to understand choices and make health care decisions. Progress notes on 11/11/25 recorded that the resident was transferred to an assisted living facility. A Notice of Transfer/Discharge dated 11/11/25 identified the assisted living facility as the transfer location and stated that the resident’s health had improved sufficiently so that facility services were no longer required. The notice form contained language about the right to appeal an involuntary or inappropriate transfer/discharge and listed the DHCS Office of Administrative Hearings and Appeals, the state LTC ombudsman, and state agencies for developmentally disabled and mentally ill individuals, along with instructions to file an appeal within 10 calendar days. However, the section for the resident or representative signature indicated only that the notice was provided to the resident’s representative via telephone and did not contain a representative’s signature, and there was no documentation that a written copy of the notice was provided to the resident or representative. During interviews regarding Resident 39, RN 3 confirmed that the resident was discharged to assisted living on 11/11/25 and that the representative was informed of the transfer/discharge via telephone. RN 3 stated she was not aware whether the facility mailed written Notices of Transfer/Discharge when residents were transferred or discharged and could not verify that a written notice was provided to Resident 39’s representative. The Medical Records Director reported that she faxed the Notice of Transfer/Discharge to the ombudsman but did not mail written notices if the resident or representative was unable to sign at the time of transfer or discharge, and she verified that she did not mail a written notice to Resident 39’s representative. For another resident (Resident 42) on the Subacute Unit (SAU), the facility’s SAU Transfer, Discharge, Bed-hold Procedure required that at the time of transfer/discharge, the patient and family member or legal representative receive a written notice of the bed-hold policy specifying the duration of the bed hold and readmission criteria. The policy also required that if a patient transferred with an expectation of return could not return, the SAU must provide written notice of transfer/discharge and reasons, send a copy to the state LTC ombudsman, and include appeal rights and contact information for the appeal entity, ombudsman, and protection and advocacy agencies. Resident 42’s record contained a Notice of Transfer/Discharge dated 1/12/26 indicating transfer to an acute care hospital because the transfer or discharge was necessary for the resident’s welfare and the needs could not be met in the facility. An SAU Form–Notice of Bedhold dated the same day showed the resident left for hospitalization and elected to hold the bed for a specified period. Progress notes for Resident 42 documented that Family Member 2 was called on 1/12/26 to inform them of the transfer to the acute care hospital. The Notice of Transfer/Discharge for that date indicated on the resident/resident representative signature line that Family Member 2 was informed via telephone of the transfer. The content of the notice included the reason for transfer and information about the appeal process if the resident or representative believed the discharge was inappropriate or involuntary. However, in a telephone interview, Family Member 2 stated they did not receive a copy of the Notice of Transfer/Discharge and were not aware of its contents. RN 3 stated that the notice was given to medical records staff and that nursing staff did not mail notices. The Medical Records Director stated she did not mail a copy of the notice of transfer/discharge to Resident 42’s responsible party and believed nursing staff mailed such notices. As a result, the resident’s interested parties did not receive the complete written information related to the transfer/discharge process, including appeal rights and bed-hold policy, as required by facility policy and regulation.
Missing informed consent for trazodone frequency change
Penalty
Summary
The facility failed to ensure informed consent was obtained for a psychotropic medication when the frequency of trazodone was changed for one resident. The facility's Psychotropic Medication Informed Consent Guide required informed consent for all residents receiving psychotropic medications and required updates when there was a medication change, including documentation of the resident's right to accept or refuse the medication, the nature of the condition, the reason the medication was prescribed, the type and specific name of the medication, the dose frequency, and the route of administration. Resident 1 was admitted with a history showing capacity to understand and make health care decisions, and the MDS described the resident as cognitively intact. The physician order sheet showed trazodone 25 mg via GT for depression as manifested by difficulty falling asleep, and the acknowledgment of psychoactive medication use documented trazodone 25 mg via enteral tube every hour of sleep as needed. Review of the medical record did not show informed consent when the trazodone frequency was changed to routine at bedtime on 12/31/25. During interview and record review, RN 6 stated that the order's reference to hours of sleep meant bedtime and confirmed there was no documented evidence of informed consent from the resident or representative for the change. The DON was informed and acknowledged the findings.
Advance Directive Missing From Medical Record
Penalty
Summary
The facility failed to ensure that a copy of Resident 13’s advance directive was available in the medical record. Resident 13 was admitted to the facility and, according to the H&P dated 9/2/25, had the capacity to understand and make healthcare decisions. The resident’s POLST dated 9/3/25 indicated that the resident did not have an advance directive, and the medical record did not contain one. During interview on 1/28/26, Resident 13 stated that she had formulated an advance directive. On 1/29/26, Family Member 1 stated that Resident 13 did have an advance directive and showed it on her phone, dated 1/20/24. Family Member 1 said she was unsure whether the facility asked about an advance directive, but she would have provided a copy if asked. The SSD stated the admission process was to ask the resident or responsible party if they had an advance directive, and RN 1 stated she was the staff member who went over the advance directive paperwork for Resident 13. RN 1 later reviewed the record and verified the POLST was wrong if the resident did have an advance directive, then spoke with Family Member 1 at the bedside and verified the resident had an advance directive.
Missing Care Plan Problems for Insulin Use
Penalty
Summary
The facility failed to develop detailed resident-centered care plans for two sampled residents who were receiving insulin. Review of the facility policy on Care Plans showed that comprehensive care plans are to be developed consistent with residents’ conditions, risks, needs, behaviors, preferences, and standards of practice, including measurable objectives, interventions, and timetables. However, review of Resident 1’s care plan dated 12/5/25 to 1/29/26 did not show a care plan problem developed to address the use of insulin, despite physician orders for insulin glargine at bedtime and insulin lispro based on blood glucose levels. Resident 22’s record showed a physician order for insulin lispro every 6 hours, and the resident’s H&P indicated no capacity to understand choices and make health care decisions. During an interview and concurrent record review, RN 6 verified that both residents were receiving insulin and confirmed there was no care plan problem initiated to address insulin use for either resident, stating insulin was identified as an intervention for diabetes but no care plan problem addressing insulin could be found. The DON was informed of and acknowledged these findings.
Failure to Document Individualized Activities
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one sampled resident, Resident 18. The resident was admitted with no capacity to understand choices and make health care decisions, had memory problems, and was dependent on staff for activities of daily living. The Activity/Therapeutic Recreation assessment documented that it was very important for the resident to listen to music and that the resident enjoyed watching television and listening to music. The care plan identified the resident as dependent on staff for activities and included interventions for one-to-one bedside or in-room visits 3-5 times per week as tolerated, with relaxation activities such as music, massage, guided imagery, and water therapy, as well as preferences for soft music, reading the daily chronicle, and CNN. On multiple observations, Resident 18 was seen lying awake in bed and staring at the wall, with the television turned off and no engagement in activities. Review of the Individual Participation Record for December 2025 and January 2026 showed no entries and did not document whether any activities were provided during those months. During interview, the Activity Director stated that music, television, and one-to-one sensory stimulation were provided, but she was unable to produce documentation to support that activities had been provided. The Activity Director verified there was no documented evidence of activity provision for those months, and the DON was informed and acknowledged the findings.
Pressure Injury Care and Special Mattress Not Properly Managed
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient for one sampled resident with Stage IV pressure injuries to the sacrum and left hip. The resident’s history and physical dated 10/8/25 documented diagnoses of Stage IV pressure injuries and noted the resident had capacity to understand choices and make health care decisions. The care plan identified alteration in skin integrity related to the left hip pressure injury and included an intervention to provide a pressure reducing mattress for skin management, but the physician order sheet did not show an order for the special mattress. On 1/28/26, the resident was observed in bed on an extra wide special mattress with display code E410 on the side of the bed and a flashing light and beeping sound at the foot of the bed. The resident stated she had told staff that her mattress did not inflate or deflate. CNA 1 and LVN 1 were unable to identify the code or had not noticed the flashing light, and RN 5 verified the error code and that the resident did not have a physician’s order for the special mattress. RN 5 also pressed on the mattress while the resident stated she could not feel it inflating or deflating.
Incomplete RNA Services and ROM Support for a Resident With Limited Mobility
Penalty
Summary
The facility failed to ensure appropriate care was provided to maintain a resident’s range of motion and mobility when restorative nursing assistant (RNA) services and instructions were not fully completed for a resident with limited ROM. The resident had severe cognitive impairment, impairment in both upper and lower extremities, and a history of contractures in both hands. The resident’s care plan included transfers from bed to wheelchair and vice versa using a Hoyer lift, passive range of motion (PROM) to both lower extremities, and right ankle PRAFO boots three times weekly as needed. The resident’s physical therapy discharge summary stated the resident would continue to be seen by CNA/RNA for bed-to-wheelchair transfers via Hoyer lift and PROM to the bilateral lower extremities, and that the mother was aware of proper donning and doffing of the right PRAFO for positioning as tolerated with skin checks. However, the physician telephone order discontinuing skilled PT and referring the resident to CNA/RNA did not include the frequency for RNA services, and it did not include an order for the right PRAFO boot or specify how long it should be worn. The Rehab Director stated the discharge recommendation did not specify how often the transfers, PROM, or PRAFO use should occur. During interview, RNA staff stated they provided services three times a week, including Hoyer lift transfers, PROM to both lower extremities, and application of PRAFO boots, but they could not explain how long the boots were kept on or whether skin checks were performed and documented. The DSD/IP stated she transcribed the therapy recommendation and communicated it to RNA staff, but acknowledged she should have clarified the frequency for transfers, PROM, and PRAFO use, as well as the duration for wearing the PRAFO boots. The DSD/IP also verified there was no order for skin checks and no documented evidence that skin checks related to PRAFO use were conducted.
Incomplete pain assessments and missing non-pharmacological pain management documentation
Penalty
Summary
The facility failed to provide safe, appropriate pain management for two residents who required pain services. The facility's Pain Management policy stated that nursing would complete an initial pain assessment on admission, including the resident's history of pain, past effective treatment, characteristics and impact of pain, and non pharmacological and pharmacological interventions. It also stated that non pharmacological interventions for pain management and/or medication would be provided as ordered by the physician. For Resident 7, the admission pain assessment was incomplete. The assessment showed the resident was asked if pain was present and marked "0. No, stop here," and the remainder of the assessment was blank. There were no other pain assessments in the record. The physician order sheet showed orders for acetaminophen 650 mg via GT every four hours PRN for pain and hydrocodone-acetaminophen 5 mg/325 mg via GT every four hours PRN for moderate pain with a pain level of 4-6. The MAR showed hydrocodone-acetaminophen was given for pain levels of 7 and 8 on some occasions, above the ordered range, and acetaminophen was also given for pain levels of 4 and 3. There was no documentation that non pharmacological interventions were attempted before these medications were administered. For Resident 13, the physician order sheet showed orders for acetaminophen 650 mg via GT PRN for mild pain, hydrocodone-acetaminophen 5 mg/325 mg routinely for pain management, and hydrocodone-acetaminophen 5 mg/325 mg, two tablets via GT PRN for moderate to severe pain. The MAR showed PRN acetaminophen and PRN hydrocodone-acetaminophen were administered for pain levels ranging from 4 to 8. There was no documentation that non pharmacological interventions were attempted before routine or PRN pain medication use. During interviews, RN 5 and RN 3 verified the lack of documentation for non pharmacological interventions, and the DON verified Resident 7's admission pain assessment did not address the resident's pain history, prior effective treatments, characteristics, or impact of pain.
Competency Failures in GT Medication Administration and Vaccine VIS Education
Penalty
Summary
The facility failed to ensure nursing staff were competent in two areas identified during survey observation and record review. During a medication administration observation for a resident with a gastrostomy tube, an LVN crushed the resident's medications and vitamins/minerals into nine separate medication cups and administered them undiluted through the GT using a medication syringe, flushing with water between each medication. The facility policy titled Medication Administration through an Enteral Tube stated medications should be crushed individually into a fine powder, reconstituted with 10-15 mL of water, mixed well, and then administered through the tube with flushing after each medication. The LVN stated the resident was not on a fluid restriction and that her usual practice was to pour crushed medications undiluted into the medication syringe for GT administration. The facility also failed to ensure the IP/DSD was aware of the Vaccine Information Statements and the need to provide residents and their representatives with education on the risks, benefits, and potential side effects of influenza, pneumococcal, and COVID-19 vaccinations. Review of a resident's Vaccine VIS Acknowledgement and Consent showed listed VIS forms for inactivated influenza vaccine, pneumococcal conjugate vaccine, pneumococcal polysaccharide vaccine, and COVID-19 vaccine/brand, but the form did not show the risks, benefits, and potential side effects of the updated vaccinations. During interview, the IP/DSD stated she provided these vaccinations to residents and their representatives before administration, but she could not show the actual updated VIS forms and stated she did not know how they looked. She also stated she did not provide the updated VIS to residents who received or declined the vaccinations.
Failure to Follow Pharmacist MRR Recommendations for Midodrine Administration
Penalty
Summary
The facility failed to follow up on the consultant pharmacist’s Medication Regimen Review recommendations related to midodrine being administered outside ordered parameters. The facility’s Medication Regimen Review policy stated the consultant pharmacist would conduct monthly reviews and make recommendations, and the facility would act on those recommendations. A pharmacist consultation report from 12/3-4/25 documented that Resident 13’s midodrine had been given when the resident’s SBP was 138, despite an order to hold the medication for SBP greater than 130, and the pharmacist recommended reminding staff about administering and holding medications within ordered parameters. The report showed other recommendations were marked as completed, but Resident 13’s recommendation was not marked done. During the unnecessary medication review, the same issue was found to have continued for two residents receiving midodrine via GT with orders to hold for SBP greater than 130. Resident 13’s January 2026 MAR showed midodrine 10 mg was administered on 1/28/26 at 0900 with an SBP of 139. Resident 7’s January 2026 MAR showed midodrine 5 mg was administered outside the ordered parameters on multiple occasions, including with SBPs of 134, 150, 143, 152, 134, and 133. The DSD stated she did not review the MRR reports and had not done staff training based on report findings, and the DON stated he and two other RNs reviewed and acted upon the pharmacist’s MRR, but he did not see the recommendation regarding Resident 13 and said he would have done a one-on-one in-service with the nurse who administered the medication.
Medication error rate exceeded threshold during crushed med administration
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, and the observed error rate was 32%. During medication administration observations, two licensed staff members were found to have medication administration errors involving crushed medications given via gastrostomy tube. The report states that these errors had the potential to negatively affect the residents' health. For one resident, an LVN crushed and administered multiple medications, including hydrocodone-acetaminophen, cetirizine, clonazepam, vitamin B-12, fluoxetine, folic acid, midodrine, oxybutynin, vitamin C, and a daily multivitamin. After administration, medication residue was observed in the medication pouches and/or cups for clonazepam, oxybutynin, cetirizine, and vitamin B-12, and the LVN verified the findings. For another resident, an RN crushed and administered vitamin D3, docusate sodium, furosemide, vitamin C, and docusate sodium/sennosides. Medication residue was observed in the pill pouches for vitamin D3, docusate sodium, furosemide, and vitamin C, and residue was also seen in the cups for furosemide, vitamin C, and vitamin D3; the RN verified the findings.
Inaccurate pain and wound documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident reviewed for unnecessary medications because the documented pain assessments did not reflect the resident’s highest pain level for the shift. Resident 7 had a physician order to monitor pain every shift on a 0 to 10 scale, and the MAR showed multiple administrations of hydrocodone-acetaminophen for pain levels ranging from 4 to 8. However, the TAR documented no pain or signs of pain for most shifts in December 2025 and January 2026, with only one January day shift showing a pain level of 2. During interview and record review, the DON verified that the resident’s highest pain level for the shift was not documented and stated the nurse had documented the pain level at the time of assessment instead. The facility also failed to keep accurate wound documentation for a resident reviewed for pressure injuries. Resident 4’s MDS showed six Stage 4 pressure injuries, including four present on admission, and no DTIs. However, the wound assessment for the left lateral head documented the wound as a DTI on multiple occasions, even though it had previously been staged as a Stage 4. The MDS Coordinator and LVN 1 both stated that once a wound is staged as a Stage 4, it remains a Stage 4 until healed, and they verified that the wound should not have been documented as a DTI after being staged at Stage 4.
Kitchen Sinks Not Maintained in Working Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a clean, sanitary, and safe operating condition for two sinks inspected in the dishwashing area. During a tour of the kitchen, Sink 1 was observed not working properly, and Sink 2 was observed with missing faucet knobs. The Dietary Manager verified these findings during the tour. Facility staff stated that work orders had been in place for both sinks since 1/6/26 to replace the kitchen faucets, and the work order status was awaiting approval. The Engineering Director later stated the sinks had been in disrepair since 1/6/26 and that replacement had not occurred because he was waiting for order confirmation to be approved by the facility.
Failure to Provide Immediate Assessment and Documentation During Resident Change of Condition
Penalty
Summary
The facility failed to meet professional standards of care for a resident experiencing a change of condition. The respiratory therapist (RT) responded to an alarming pulse oximeter for a resident with severe cognitive impairment, who was found to be lethargic, unresponsive, and jaundiced. The RT attempted to troubleshoot the pulse oximeter, changed the sensor, and suctioned the resident without first checking the resident's pulse or lung sounds. Despite the resident's continued unresponsiveness and abnormal appearance, the RT did not immediately call for assistance, instead spending approximately five to eight minutes performing interventions before activating the emergency response. During this period, the RT did not document any of the actions or interventions provided to the resident, as required by facility policy and professional standards. The RT only checked the resident's pulse after other interventions failed to yield a response, at which point no pulse was detected and emergency assistance was finally summoned. The delay in calling for help and the lack of documentation were confirmed through interviews with the RT, the Director of Nursing (DON), and the RT Supervisor, all of whom stated that immediate assessment and rapid response are expected in such situations. Facility policy and professional standards, as well as statements from the DON and RT Supervisor, indicate that licensed staff are required to promptly assess residents for consciousness, breathing, and pulse, and to call for help within less than a minute if a resident is unresponsive or in distress. The RT's actions did not align with these expectations, and the absence of documentation further failed to meet the facility's requirements for recording care provided during a change of condition.
Failure to Obtain Physician Orders, Informed Consents, and Complete Wound Assessments for Debridement Procedures
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for one resident. Specifically, the facility did not obtain the required physician's orders and informed consents prior to performing bedside debridement procedures on the resident's scrotal and perineal/perianal wounds. Facility policy required a new and separate consent for each debridement session, and the procedure listed on the consent was to match the physician's order. However, review of the medical record showed that for two debridement procedures, there were no corresponding physician orders, and for one of the procedures, no informed consent was obtained or signed. Additionally, the consent obtained for one procedure did not match the procedure actually performed, as documented in the physician's operative report. Further, the facility failed to ensure that wound assessments were completed after the bedside debridement procedures. According to facility policy and staff interviews, wound assessments should be performed after each debridement, including documentation of wound measurements, drainage, and tissue type. Review of the resident's wound assessments revealed that after the debridement procedures, there was no documentation of wound measurements or assessments for the scrotal and perineal/perianal wounds. This lack of documentation occurred both immediately following the procedures and in subsequent weekly assessments. The resident involved had severely impaired cognitive skills for daily decision making and was admitted with significant wounds requiring ongoing care. Despite the complexity of the resident's condition and the need for careful monitoring, the facility did not follow its own policies regarding consent, physician orders, and wound assessment documentation. These failures were confirmed by interviews with the DON and LVN, who acknowledged that the required documentation and consents were missing from the medical record.
Failure to Provide Appropriate Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services related to pressure injuries for three residents reviewed for wound management. For one resident with a Stage 4 sacrococcyx pressure injury, the wound increased in size and necrotic tissue, but there was no documentation that the Wound Care Physician was informed of these changes. The wound assessments showed a progression from partial granulation and necrotic tissue to 100% necrotic tissue and an increase in wound size over several weeks. Interviews with nursing staff confirmed that the physician should have been notified and that this notification should have been documented, but this did not occur. For two other residents, the facility failed to ensure that the Low Air Loss (LAL) mattress settings were consistent with each resident's current weight. One resident, weighing 141 pounds, was observed with the LAL mattress set for a weight range of 165 to 250 pounds, which did not match the resident's actual weight. Another resident, weighing 119 pounds, was observed with the LAL mattress set at 300 pounds. Staff interviews confirmed that the mattress settings should correspond to the resident's weight and that incorrect settings could affect wound healing. The responsible nurses did not check or adjust the mattress settings during wound care. Facility policies required individualized care plans, regular wound assessments, and appropriate use of pressure-redistributing support surfaces. Documentation and staff interviews revealed that these policies were not consistently followed, as evidenced by the lack of physician notification for wound deterioration and improper mattress settings for residents at risk for or with existing pressure injuries.
Failure to Attempt Least Restrictive Alternatives Before Using Bed Rails
Penalty
Summary
The facility failed to ensure that the least restrictive alternatives were attempted before the use of side rails for several residents. This deficiency was identified through observations, interviews, medical record reviews, and policy and procedure reviews. The facility's policy on restraints and bed rails required that appropriate alternatives be attempted before installing bed rails, but this was not documented or evidenced in the medical records of the residents reviewed. For instance, Resident 12 was observed with elevated side rails, and their medical record did not show any documented evidence of attempts to use less restrictive alternatives before the side rails were applied. Similarly, Resident 25 was found with all four side rails elevated, and their medical record also lacked documentation of attempts to use less restrictive measures. Interviews with staff confirmed the use of side rails and the absence of documentation for alternative measures. Other residents, including those who lacked the capacity to make healthcare decisions, were also found with elevated side rails without documented evidence of attempts to use less restrictive alternatives. The facility's staff, including CNAs, LVNs, and RNs, verified the use of side rails and acknowledged the lack of documentation for alternative measures. The Director of Nursing was informed and acknowledged these findings, indicating a systemic issue in the facility's adherence to its policy on the use of restraints and bed rails.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as evidenced by multiple observations during a survey. The ice machine, which was used by both residents and staff, was found to have a thick, yellowish residue on its interior top portion, indicating it was not cleaned according to the facility's policy and manufacturer's specifications. This was acknowledged by the Operational Engineer, who stated the ice would not be used due to its dirty condition. Additionally, the microwave used for warming food was observed to be dirty, with dry, white food residue and stains inside. The Culinary Service Manager confirmed the microwave's condition and noted it was old and needed replacement. The kitchen hood over the stove was also found to have black, grease residue, which the Culinary Service Manager acknowledged as a fire hazard, despite the dietary staff's weekly cleaning schedule. The facility's kitchen utensils and equipment were in poor condition, with several items such as ladles, potato mashers, strainers, and spatulas found to be dirty, discolored, or damaged. The Culinary Service Manager verified these findings and agreed that the items needed to be discarded and replaced. Furthermore, the cutting boards were heavily marred and had deep grooves, making them difficult to clean and sanitize. Expired sanitizer test strips and expired food items were also found, which could lead to inaccurate testing and potential foodborne illnesses.
Incomplete Entrapment Assessments and Documentation in LTC Facility
Penalty
Summary
The facility failed to ensure complete entrapment assessments and proper documentation of bed rail measurements for several residents, which could lead to potential entrapment, serious injury, or death. The report highlights that the facility did not complete entrapment assessments for Zones 5 and 6 for multiple residents, including those who were sampled and nonsampled. This lack of documentation and assessment was observed during facility tours and interviews with staff, where it was confirmed that the necessary measurements were not recorded. For instance, Resident 12 was observed with elevated side rails, yet the entrapment assessment for Zones 5 and 6 was incomplete. Similarly, Resident 25 had all four side rails elevated, but the documentation failed to show assessments for the same zones. Interviews with CNAs and LVNs confirmed the use of side rails for repositioning, but the necessary safety assessments were not documented. The report also notes that the responsibility for completing these assessments was unclear, with some staff indicating that the engineering or maintenance department was responsible, while others stated it was the nursing staff's duty. The report further details that the facility's policies and procedures require the assessment of bed dimensions and the risks and benefits of side rail use. However, these procedures were not followed, as evidenced by the lack of documented measurements for several residents. Interviews with the Director of Nursing (DON) and other staff members confirmed the findings, indicating a systemic issue in the facility's adherence to safety protocols regarding bed rail use and entrapment risk assessments.
Deficiencies in GT Care and Labeling
Penalty
Summary
The facility failed to provide proper care for residents with gastrostomy tubes (GT), as evidenced by the lack of labeling on feeding bottles, water irrigation bags, and irrigation sets for two residents. Resident 15 and Resident 24 had their GT feeding formula and irrigation equipment without labels indicating the name and date, which was confirmed by LVN 5 during observations. The facility's policy requires labeling with two identifiers, feeding rate, and hang date and time, which was not adhered to in these cases. Additionally, the facility did not change the GT dressings daily as ordered for Residents 17 and 32. Both residents lacked the capacity to make healthcare decisions, and their physician orders specified daily dressing changes to maintain site hygiene and monitor for infection. Observations revealed that the dressings were not changed as required, with LVN 5 admitting to missing the changes. RN 1 confirmed that the dressings should be changed daily for continuous assessment, and the DON acknowledged these findings.
Failure to Document and Plan PICC Line Care
Penalty
Summary
The facility failed to provide necessary care and services for maintaining the intravenous accesses for a resident, specifically regarding the use of a PICC line. The facility did not ensure that the external catheter length and arm circumference measurements were completed and documented in the medical record for the resident. Additionally, there was no care plan developed for the use of the PICC line. These omissions were identified through a review of the facility's policies and procedures, medical records, and interviews with staff members. The medical record review revealed that upon admission, there was no documentation of the PICC line measurements, which is required for monitoring potential complications. Interviews with the LVN and RN confirmed the lack of documentation and the absence of a care plan for the PICC line. The Director of Nursing was informed and verified these findings, indicating a lapse in the facility's adherence to its own policies and procedures regarding intravenous care management.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as evidenced by multiple observations and interviews. For instance, the nasal cannulas for some residents were not labeled with the date they were changed, and there were no plastic bags for storage when not in use. This was observed in residents who required oxygen therapy, and the lack of proper labeling and storage was acknowledged by the staff, including the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). Additionally, the facility did not ensure that nebulizer equipment was properly labeled and stored. In one case, a resident's nebulizer mask, tubing, and bag were not dated, and there was no plastic bag for storage. The LVN confirmed that these items should have been dated and stored correctly. Furthermore, the facility failed to follow the manufacturer's maintenance care instructions for a BiPAP machine used by a resident, as there was no specific order for cleaning and maintenance per the manufacturer's guidelines. The facility also neglected to provide necessary signage for oxygen usage in residents' rooms, which is crucial for hazard precautions. Several residents' oxygen tubing was found unlabeled, undated, and in some cases, touching the floor, which poses a risk of contamination. These deficiencies were verified by the LVN and acknowledged by the DON, indicating a systemic issue in maintaining proper respiratory care protocols within the facility.
Failure to Follow Pureed Recipe for Steamed Green Beans
Penalty
Summary
The facility failed to adhere to the pureed recipe for steamed green beans for two residents who were on a pureed diet. The facility's document titled Patient Diet List indicated that these residents received pureed food from the kitchen without restrictions to steamed green beans. The Menu Plan Fall Winter 2024 included steamed green beans for the PU4 pureed diet. However, during the preparation of the pureed steamed green beans, the recipe was not followed as required. The recipe specified blending the green beans with three tablespoons of food thickener per 10 servings to achieve a smooth, pudding-like texture. Instead, the preparation involved adding half quarts of vegetable juice and an incorrect amount of food thickener, resulting in a runny consistency. During an observation and interview, it was confirmed by RD 2 that the pureed steamed green beans did not hold a form and were runny, indicating the recipe was not followed. RD 2 acknowledged that the pureed recipe should have been adhered to and that the final product should hold a shape and not be runny. Additionally, RD 2 noted that not following the recipe and adding more food thickener could increase the calorie content of the diet, potentially affecting the nutritional balance intended for the residents on a pureed diet.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as evidenced by several deficiencies. There were missing records for the temperature log of the Medication Room and Medication Refrigerator on specific dates, which was confirmed by RN 5 and the Director of Nursing (DON). Additionally, an empty bottle of Hy[DATE] was found in the Treatment Cart, which should have been disposed of, as verified by LVN 5 and the DON. Furthermore, Medication Cart 1 was observed to have medication residue spillage, which was acknowledged by LVN 4 and confirmed by the DON. Resident 22 was affected by the facility's failure to label medications with an opened date. A bottle of 1000 ml of 0.9% sodium chloride irrigation was found opened and undated on the resident's overhead table. LVN 1 confirmed that the bottle did not have an opened date and should have been either discarded after the first use or dated by the staff. The DON was informed and acknowledged these findings. These failures had the potential to negatively impact the residents' well-being.
Failure to Ensure Privacy for Resident with Catheter
Penalty
Summary
The facility failed to ensure the dignity and privacy of Resident 10, who was one of the twelve residents sampled in the survey. Resident 10 had a medical diagnosis of neuromuscular dysfunction of the urinary bladder and had an indwelling urinary catheter as per a physician's order dated 9/26/24. The order specified that the catheter drainage bag should be placed inside a dignity bag every shift to maintain the resident's privacy. However, during an observation on 11/20/24, it was noted that Resident 10's catheter drainage bag, containing 100 ml of urine, was not placed inside the dignity bag. Instead, the dignity bag was found on the left side of the bed, while the catheter bag was on the right side. Interviews conducted with the facility staff, including RRT 1, RN 2, and the DON, confirmed the oversight. RRT 1 acknowledged that the catheter bag should have been inside the dignity bag. RN 2 explained that the dignity bag is used to ensure the urine is not visible, thereby maintaining privacy. The DON reiterated that the facility provides dignity bags for all residents with indwelling urinary catheters and that failing to use them as intended violates the residents' privacy. This oversight in following the physician's order and facility protocol resulted in a deficiency concerning the resident's right to privacy and dignity.
Improper Garbage Storage in Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage in four out of nine dumpsters, as observed during a survey. The facility's policy and procedure for waste management, revised in June 2022, requires that dumpster lids or doors be closed before leaving the area and that no trash be left alongside or on top of the dumpsters. Additionally, the 2022 FDA Food Code mandates that outside garbage receptacles have tight-fitting lids to prevent pest attraction. During an observation and interview with the EVS Manager, it was noted that the lids of four dumpsters were partially propped open by garbage, preventing them from fully closing. The EVS Manager confirmed these findings and acknowledged that the lids should be fully closed to prevent animal intrusion and address infection control concerns.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved CNA 1 yelling at Resident 1, making derogatory comments about the resident's personal life, and breaking confidentiality by discussing the resident's personal issues with other staff. The verbal exchange occurred after Resident 1 repeatedly pressed the call light, seeking to speak with a social worker about her discharge. CNA 1, frustrated by the repeated calls, made inappropriate comments to the resident, which were overheard by other staff members. The facility's investigation confirmed the verbal abuse, and it was noted that CNA 1 had a history of unprofessional behavior. The facility staff failed to report the incident in a timely manner, as required by the facility's policies and procedures (P&P). The Director of Nursing (DON) was not informed of the incident until Resident 1 filed a complaint. There was no documentation or care plan addressing the verbal altercation between Resident 1 and CNA 1. The lack of timely reporting and intervention by the staff potentially exposed the resident to psychosocial harm, as the facility's P&P mandates immediate reporting of any alleged abuse to the appropriate authorities.
Failure to Address Resident's Skin Discoloration
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident maintained their highest physical well-being. Resident 2, who was cognitively intact and capable of making healthcare decisions, developed a new skin discoloration on her right wrist. Despite the facility's policy requiring communication with healthcare providers upon recognition of a significant change in status, the staff did not notify the physician, create a care plan, or monitor the skin discoloration. The resident, who was on anticoagulant medication, noticed the discoloration two days prior but did not recall informing the staff. A CNA observed the discoloration and reported it to an LVN, but there was no documentation in the medical record regarding the incident. An RN confirmed that a new skin assessment was not completed, even though the discoloration was identified the previous day. The lack of documentation and follow-up on the resident's condition indicates a failure to adhere to the facility's policy on managing changes in a resident's medical condition.
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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 Brea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Vista At Morningside | 2.8 mi | ★★★★★ | 21 | 0 |
| St Elizabeth Healthcare Center | 3.2 mi | ★★★★★ | 25 | 0 |
| The Pavilion At Sunny Hills | 3.4 mi | ★★★★★ | 9 | 0 |
| Greenfield Care Center Of Fullerton, Llc | 3.5 mi | ★★★★★ | 15 | 0 |
| Terrace View Care Center | 3.5 mi | ★★★★★ | 28 | 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.