Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Las Colinas Post Acute during CMS and state inspections, most recent first.
Failure to notify a resident representative of a hospital transfer: A resident with a left femur fracture, bone CA, DM2, and HTN developed ALOC with abnormal VS, including elevated BS and low O2 sat, and EMS was called. The DON stated the resident's spouse was upset because she was not informed of the transfer; the face sheet and POLST had different phone numbers, and the Admissions Coordinator entered the contact information that led to the missed notification.
Incorrect spouse contact information on a resident’s face sheet led to the spouse not being notified of the resident’s hospital transfer. The resident, who had a left femur fracture, bone cancer, DM2, and HTN, developed ALOC, became difficult to arouse, and had abnormal VS including elevated blood sugar and low O2 saturation before an emergency response was called. The DON stated the face sheet and POLST listed different phone numbers for the spouse, and the Admissions Coordinator entered the face sheet information.
Unlabeled food was found in a shared resident refrigerator in the family room. Kitchen staff observed a closed bag of noodles and a plastic container of soup without the required resident name, room number, and date. The KS and DFNS confirmed that food stored in the refrigerator must be labeled, and the facility policy stated that outside food not labeled and dated may be discarded.
The facility failed to follow infection control practices during resident care and equipment handling. A CNA did not perform hand hygiene before and after applying a nasal cannula to a resident, an incentive spirometer was left unlabeled and improperly stored at a resident’s bedside, two laundry dryers were operating below the required temperature, a glucometer was not disinfected between resident uses, and an LPN did not disinfect a BP device before measuring a resident’s BP. The DON, IP, and other staff acknowledged the lapses.
Laundry Dryers Not Heating Properly: Surveyors observed three dryers in use on the High setting, but two dryers were only 100 and 140 degrees Fahrenheit while the facility log recorded 180 degrees for all three. The ESD, Laundry Staff, MTD, and DON all confirmed the low temperatures, and the dryer manual showed the high heat thermostat should operate around 185/170 degrees Fahrenheit. Facility policy required laundry equipment to be maintained per the manufacturer's IFU and kept in safe, operable condition.
Main entrance door gaps and a door that did not always close properly created entry points for pests. An Orkin report had already identified open gaps in the front exterior door and recommended weather stripping, but documentation of the repair was not available. Residents reported mosquitoes and occasional bugs, and a fly was observed near a nursing station. The MTD and ADM both acknowledged the gaps and that pests could enter through the entrance.
Advance care planning was not completed properly for multiple residents. One resident’s POLST was left incomplete, with blank sections for CPR, medical interventions, and artificial nutrition, and it lacked the resident or legal decision-maker signature. Several other residents had no documentation showing they received written info about advance directives, one resident’s POLST incorrectly showed an advance directive existed, and staff confirmed in multiple cases that no acknowledgement or proof of advance directive discussion was in the record.
The facility failed to keep two residents free from unnecessary psychotropic medication use. One resident received PRN Ativan without non-drug interventions being offered first on multiple occasions, despite an order requiring those interventions before anti-anxiety medication. Another resident received Depakote without an accurate diagnosis documented in the record; the psych note said it was being used for seizure disorder, but the physician later stated that diagnosis was an error and the intended indication was impulse control.
Inaccurate Hearing Assessment and MDS Coding: A resident stated being hard of hearing and needing others to speak loudly, and reported that hearing aids brought on admission were broken. Record review showed hearing loss in the H&P and hearing aids listed on admission documents and the Social History assessment, but the MDS coded the resident as hearing adequately and not using hearing aids. The DON and MDSD confirmed the hearing disability was not accurately reflected in the assessment records.
Failure to Care Plan Hearing Disability: A resident with documented hearing loss and hearing aids on admission reported being hard of hearing and needing others to speak loudly, but the facility did not develop a comprehensive care plan for the hearing disability. The DON confirmed no comprehensive care plan was in place, and the MDS was inaccurately coded as hearing adequate and no hearing aids, despite records showing the resident used hearing aids.
Failure to update care plans after orders changed. Two residents had outdated plans of care: one still listed vascular access concerns after a peripheral IV had been discontinued, and another still listed enhanced barrier precautions after the order was stopped. RN, LVN, and DON interviews confirmed the care plans were not revised when the residents' conditions changed, despite facility policy stating care plans are revised as resident condition changes.
Failure to Replace Broken Hearing Aids: A resident with hearing loss reported that hearing aids received on admission were broken, and the resident said the issue had been reported to SS. Records showed hearing aids were listed on admission documents and adaptive aids assessments, while audiology notes documented hearing problems. A CNA confirmed ongoing hearing difficulty, the MDSD said section B was not accurately assessed, and the DON confirmed the hearing aid need had not been addressed.
Failure to assist a resident with hearing aid replacement. A resident with a hx of hearing loss reported that the hearing aids brought on admission were broken and that staff had been told about the need for replacement. Records showed the resident used hearing aids and glasses, and audiology noted abnormal hearing by observation. A CNA confirmed ongoing hearing difficulty for months, and the DON stated the resident’s hearing aid needs had not been addressed despite the facility policy requiring staff to help residents replace lost or damaged hearing devices.
A resident with acute respiratory failure with hypoxia and COPD had a continuous oxygen order for 2 LPM via NC or mask to keep O2 saturation above 88%, but the oxygen concentrator was observed turned off at the bedside. An LVN and RN confirmed the oxygen was not being administered continuously as ordered, and the DON later confirmed the lapse before the physician changed the order to PRN.
Delayed e-Kit Replacement and Incomplete Usage Documentation: The facility failed to promptly replace used e-Kits and did not accurately complete e-Kit Usage Slip forms. During inspection, multiple e-Kits were found secured with black zip ties, indicating prior use, and RN staff confirmed that used kits should be reported to the pharmacy and documented on a usage slip left in the kit. Review of the slips showed missing resident and medication information on some entries, including lorazepam, acetaminophen with codeine, and potassium chloride. The DON confirmed the kits needed prompt replacement, and the facility could not provide specific P&P for emergency supply replacement of controlled and non-controlled oral meds.
Unsafe medication storage was observed when loose unidentified tablets were found in a med cart drawer, an expired tube of Silvasorb gel remained in a med room, and cleaning products were stored in the same compartments as oral and topical medications. LVN and RN staff confirmed the findings, and the DON acknowledged that expired meds should have been discarded and cleaning solutions kept separate from medications.
A facility failed to ensure that eight of 11 sampled residents knew where to find the survey results binder. During a resident council meeting, most residents polled did not know its location, and the DON and ADM later confirmed the binder was located without any signs posted at that site or elsewhere in the facility.
Insufficient room space was identified in five 3-bed resident rooms after the ADM acknowledged that some rooms did not meet the required square footage. During the environmental tour, the MTD measured each room at about 223 to 223.54 sq. ft. total, which provided only 74.3 to 74.5 sq. ft. per resident, below the 80 sq. ft. requirement.
A resident with multiple chronic conditions was not provided with a dental assessment within ninety days of admission, as required by facility policy. Both the resident and the DON confirmed that no dental services had been provided since admission, and record review supported this finding.
A resident was found with blanchable redness on the face after a shower, following complaints from the resident's wife about hot water and rough scrubbing by a CNA. Despite the facility's policy to report such incidents, the DON and Administrator did not report it to the CDPH, as they did not perceive it as abuse due to a lack of malicious intent. The IDT reviewed the incident but did not include the resident or the resident's wife in the meeting.
A facility failed to maintain an accurate MAR for a resident with liver failure and ESRD. An LVN did not sign the MAR for a scheduled dose of Lactulose, a medication to reduce ammonia levels, potentially leading to the resident's hospital readmission. The DON confirmed that unsigned medications are considered not given, and the LVN admitted to not signing the MAR despite believing she administered the medication.
A resident with a foley catheter was not monitored per shift as ordered, with missing documentation for multiple shifts. The resident, with a history of hemiplegia, epilepsy, COPD, and UTIs, was sent to an acute hospital after a change in condition. The facility's policies on documentation were not followed, as revealed by interviews with the ADON and an LVN.
The facility did not follow its policies for providing ADLs and timely response to call lights for two residents. One resident with chronic respiratory failure and other conditions reported delays in assistance, while another with respiratory failure and diabetes experienced similar issues. The facility's policies require prompt response to call lights and care to maintain residents' abilities, which were not adhered to.
A resident admitted without wounds developed a stage 4 pressure injury and multiple blisters while under care, despite being at high risk for skin breakdown. The facility's interventions, such as protective lotion and pressure-reducing mattresses, were insufficient, leading to significant skin deterioration. Staff acknowledged the resident's poor circulation and immunocompromised state but admitted the wounds could have been prevented.
Two residents in the facility experienced significant delays in response to their call lights, impacting their care. One resident, with cerebral ataxia and hypothyroidism, reported waiting up to two hours for assistance, particularly during the PM shift. Another resident, with heart failure, also faced excessive delays, sometimes using a phone to contact the desk for quicker help. Both residents' care plans required prompt response to call lights due to their medical conditions and deficits in activities of daily living.
A resident was discharged with four medication packs not prescribed to them, resulting from a failure to follow the facility's medication verification process. The resident's post-discharge plan of care did not match the medication orders, and a critical medication was missing.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to implement its Change in a Resident's Condition or Status policy for one resident when the resident's spouse was not informed of the resident's transfer to the hospital. The resident was admitted with diagnoses including a left femur fracture, bone cancer, type 2 diabetes mellitus, and hypertension. On April 6, 2026, nursing notes documented an altered level of consciousness: the resident was responsive at 6:00 AM, then could not be aroused at 7:40 AM when a CNA brought a meal tray. The charge nurse assessed the resident as not responsive to name and hard to arouse, with vital signs showing blood pressure 136/81, heart rate 140, blood sugar 448, and oxygen saturation 80% on room air. The RN then assessed the resident, administered oxygen by mask, and at 7:50 AM the resident's vital signs were blood pressure 140/98, blood sugar 440, oxygen 97% on NRB 4L, and pulse 126, after which emergency response was called. During interview and record review, the DON stated the resident's spouse was upset and reported not being informed of the transfer to the hospital. The DON reviewed the resident's face sheet and POLST and stated the forms contained different phone numbers for the spouse. The DON further stated the Admissions Coordinator entered the information on the face sheet, which led to the spouse not being notified of the transfer. The facility policy stated it promptly notifies the resident, attending physician, and resident representative of changes in medical or mental condition or status, and that family or representative contact information is to be verified quarterly and updated in the medical record when changes are noted.
Incorrect Spouse Contact Information Led to Missed Hospital Transfer Notification
Penalty
Summary
The facility failed to ensure its Charting and Documentation, Change in a Resident Condition or Status policy and procedure was implemented for one sampled resident when the resident’s face sheet listed an incorrect phone number for the resident’s spouse. The resident was admitted with diagnoses including a left femur fracture, bone cancer, type 2 diabetes mellitus, and hypertension. On April 6, 2026, nursing documentation showed the resident had an altered level of consciousness, was responsive at 6:00 AM, then could not be aroused at 7:40 AM when a CNA brought a meal tray. The charge nurse assessed the resident as not responsive to name and hard to arouse, with vital signs including blood pressure 136/81, heart rate 140, blood sugar 448, and oxygen 80% on room air. The RN then assessed the resident and applied a non-rebreather mask, with subsequent vital signs of blood pressure 140/98, blood sugar 440, oxygen 97% on NRB 4L, and pulse 126. Emergency response was called. During interview and record review, the DON stated the resident’s spouse was upset and said she had not been informed of the resident’s transfer to the hospital. The DON reviewed the resident’s face sheet and POLST and stated the forms had different phone numbers for the spouse, and that the Admissions Coordinator encoded the information on the face sheet, which led to the spouse not being notified of the transfer.
Unlabeled Food in Shared Resident Refrigerator
Penalty
Summary
The facility failed to label food brought in by family and other visitors for one unsampled resident, Resident 121. During an observation in the family room with Kitchen Staff, a closed black bag containing noodles and one plastic container of soup without a label were found inside the shared residents’ refrigerator for food brought in by family and visitors. A posting outside the refrigerator stated that all food must have the resident’s name, room number, and date, and that any missing information would result in the food being thrown out. Kitchen Staff stated that all food stored in the residents’ refrigerator must be labeled with the room number and resident’s name. The Director of Food and Nutritional Services confirmed that all food inside the shared residents’ refrigerator is supervised by kitchen staff and must be labeled with the resident’s name and room number. The facility policy titled Food Receiving and Storage dated 1/2024 stated that the facility has the right to dispose of any food from outside sources that is not labeled and dated accordingly.
Infection Control Failures During Resident Care and Equipment Handling
Penalty
Summary
The facility failed to implement infection prevention and control measures during resident care and equipment use. During an observation outside a resident’s room, a CNA applied a nasal cannula to the resident without performing handwashing before or after handling the cannula. The CNA stated handwashing should be performed before and after applying a nasal cannula to prevent bacterial infection, and the LVN and IP confirmed that hand hygiene was required for resident care and infection control. The resident had diagnoses including shortness of breath and orthostatic hypotension, and the facility policy stated hand hygiene is indicated immediately before touching the resident, after touching the resident, and after touching the resident’s environment. An incentive spirometer was observed at another resident’s bedside unlabeled, uncovered, and not stored in a protective bag. The IP verified the item was not stored appropriately and stated it should not be left exposed because it could cause an infection if placed in the resident’s mouth. Record review showed the resident’s incentive spirometer order had started and ended earlier in the month, and the DON stated licensed nurses were responsible for assisting with the device and discarding it when the order was completed. The resident had diagnoses including essential hypertension and type 2 diabetes mellitus, and the care plan referenced incentive spirometer use for pulmonary hygiene. In the laundry area, two of three dryers were observed operating at 140 degrees Fahrenheit and 100 degrees Fahrenheit, while the facility log recorded 180 degrees Fahrenheit for all three dryers throughout the month. The ESD, maintenance director, IP, and DON all acknowledged the temperatures were below the normal range, and the laundry staff stated the dryers were opened every 15 minutes to prevent linens from burning. In addition, a glucometer used for three residents was not disinfected before and after each use, and an LVN did not disinfect a BP device before measuring a resident’s BP. The LVN acknowledged the omission, and the DON confirmed the glucometer should have been disinfected before and after use for each resident and that the BP device should have been disinfected before and after measuring BP.
Laundry Dryers Not Heating Properly
Penalty
Summary
The facility failed to ensure that two of three laundry dryers were heating properly according to the manufacturer's recommendations. During a tour of the laundry area on 8/26/25 at 2:23 PM, all three dryers were in use on the High setting, with Dryer 1 holding towels, Dryer 2 holding bed sheets, and Dryer 3 holding residents' clothes. The observed temperatures were 140 degrees Fahrenheit for Dryer 1, 230 degrees Fahrenheit for Dryer 2, and 100 degrees Fahrenheit for Dryer 3. A review of the August 2025 Dryer Temperature Log showed all three dryers were recorded at 180 degrees Fahrenheit from 8/1/25 through 8/26/25. During interviews, the ESD stated the temperature issue should be reported to maintenance because dryer temperature was required to be at least 180 degrees Fahrenheit. The Laundry Staff stated the dryers were opened every 15 minutes to prevent towels and linens from burning and said the temperature decreased in the afternoon. The MTD stated there might be an issue with the thermostat and that it needed to be replaced, and confirmed that two dryers were below the normal range. The DON also confirmed that dryer temperatures of 100 and 140 degrees Fahrenheit were low and stated it was the facility's responsibility to maintain the equipment in good condition. The dryer manual indicated the high heat thermostat should open at 185 degrees Fahrenheit and close at 170 degrees Fahrenheit, and facility policy required laundry equipment to be maintained according to the manufacturer's IFU and kept in a safe and operable manner.
Main Entrance Door Gaps Allowed Pest Entry
Penalty
Summary
The facility failed to ensure the main entrance door frame was sealed and the door closed properly, creating entry points for pests. During observation at the main entrance, gaps were noted in the door frame, and later observations confirmed the door was not closing properly. The Maintenance Service Director stated the gaps were visible on the sides, middle, and bottom of the door and that pests would be able to enter. The Administrator also stated that the gaps in the main entrance door made it easier for pests to enter the facility and that the door did not always close properly. The Orkin pest control report dated 6/16/25 identified open gaps in the front exterior door and recommended adding weather stripping. During interviews, a resident reported being bitten by a mosquito three days earlier and believed mosquitoes were entering through the main entrance when people came and went. Another resident stated bugs were seen occasionally, particularly when food trays were in the room. A fly was also observed near nursing station three. The Maintenance Service Director stated a note had been written in the maintenance book about weather stripping but could not provide documentation to verify that the repair had been completed.
Incomplete Advance Care Planning and Missing Advance Directive Documentation
Penalty
Summary
Advance care planning was not completed properly for multiple residents, including failures to obtain or document advance directive information and an incomplete POLST form. For Resident 141, the POLST form was incomplete: Section A for CPR, Section B for Medical Interventions, and Section C for Artificially Administered Nutrition were left blank, and Section D contained the physician signature but did not include the signature of the patient or legal decision-maker. The DON stated POLST forms should be completed within 48 hours of admission and reviewed during the care conference, and facility policy stated a valid POLST must be signed by the physician and the patient or decision-maker. For Resident 170, the record showed the resident had capacity to understand and make decisions, but there was no documentation that the resident received written information about advance directives. The SSD reviewed the facility policy and acknowledged that the facility provides an Information Sheet Advance Care Directives during admission and annually, but the resident’s record did not contain documentation showing the written information was provided electronically or physically. The SSD verified that no such documentation was present. For Resident 13, the POLST inaccurately indicated an advance directive existed when the SSD verified the resident did not have one. For Resident 96 and Resident 10, the POLST forms had incomplete Section D entries regarding advance directives, and the records did not contain written information showing advance directive education was provided. Resident 10 also stated during interview that the resident had not been informed about advance directives and had not received written information on how to formulate one. For Resident 76, the SSD and DON confirmed there was no written acknowledgement provided to the resident and/or family member to formulate an advance directive. For Resident 15, the DON confirmed there was no proof that an advance directive was offered, and the MDSD confirmed there was no advance directive in the record. For Resident 8, the DON confirmed the resident or representative did not sign the acknowledgement receipt showing advance directives were offered.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Resident 162 was kept free from unnecessary psychotropic medication use when non-pharmacological interventions were not consistently offered before PRN Ativan was administered. Resident 162 was admitted with a diagnosis including anxiety, and the physician had ordered non-drug intervention prior to administration of PRN anti-anxiety medication. Review of the August 2025 MAR showed that non-pharmacological interventions were not offered before Ativan was given on multiple occasions, including 8/5/25, 8/15/25, 8/16/25, and 8/26/25. During interview, LVN 2 was unable to explain why the interventions were not offered, and the DON later verified that they should have been offered before each administration. The facility also failed to ensure that Resident 12 received Depakote only for a clinically indicated diagnosis documented in the medical record. Resident 12 was readmitted with a diagnosis including dementia, and the face sheet later added epilepsy on 8/22/25. A psychiatric follow-up note dated 8/22/25 stated that Resident 12 was taking Depakote for seizure disorder, not psychosis. When the DON contacted the physician, the physician stated the seizure disorder diagnosis was an error and that the indication should be impulse control. The facility policy stated psychotropic medications should be clinically indicated and necessary to treat a specific condition documented in the medical record, with behavioral and other non-pharmacological approaches used unless contraindicated.
Inaccurate Hearing Assessment and MDS Coding
Penalty
Summary
The facility failed to comprehensively and accurately assess hearing for one resident, identified in the report as Resident 68. During a concurrent observation and interview, the resident stated having hard of hearing and needing people to speak loudly to hear them. The resident also stated having hearing aids upon admission in September 2023, but that they were broken, and said Social Services had been informed about the need to replace the hearing aid. Record review showed the resident was admitted on [DATE], had a history and physical dated 10/2/24 listing hearing loss, and had admission records indicating right and left hearing aids on the Inventory of Personal Effects Form dated 9/19/23. The resident’s Social History assessment also listed hearing aids and glasses under Adaptive Aids. However, the MDS dated 9/26/23 and 6/28/25 coded the resident as hearing adequately and not using hearing aids. The DON verified that information regarding the resident’s hearing disability did not appear in the assessment records, and the MDSD confirmed that section B of the MDS was not accurately assessed for the resident.
Failure to Care Plan Hearing Disability
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the hearing difficulty of Resident 68. During a concurrent observation and interview on 8/25/25, Resident 68 stated having hard of hearing and needing people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but that they were broken, and said Social Services had been informed about the need to replace the hearing aid. Record review showed Resident 68 had a diagnosis of hearing loss in the H&P dated 10/2/24. The admission inventory of personal effects dated 9/19/23 documented right and left hearing aids, and the social history assessment indicated the resident used hearing aids and glasses. However, the MDS dated 9/26/23 and 6/28/25 indicated the resident hears adequately and does not use hearing aids. During interview and record review, the DON confirmed Resident 68 did not have a comprehensive care plan for hearing disability, and the MDSD stated the facility did not inquire whether residents had hearing aids and confirmed Section B of the MDS for Resident 68 was not accurately assessed.
Failure to Update Care Plans After Orders Changed
Penalty
Summary
The facility failed to revise the care plan for two residents after their conditions changed. For Resident 12, the record showed a peripheral IV was started on 7/15/25 and discontinued on 7/18/25, but the care plan still contained a problem dated 7/15/25 for vascular access and risk for complications due to the presence of a peripheral line. During interview, RN 4 stated Resident 12 no longer had a current peripheral IV access line and that the care plan should have been revised because staff were monitoring for something that was no longer an issue. For Resident 162, the plan of care still indicated enhanced barrier precautions even though the order had been discontinued. During interview and record review, LVN 2 stated she would look at the plan of care to know how to care for the resident and said she did not know the order for enhanced barrier precautions had been discontinued because the plan of care was not updated. LVN 3 stated the nurse who discontinued the order should revise the plan of care, at least the same day, and the DON stated the care plan should have been updated at the time the order was changed. The facility policy stated assessments are ongoing and care plans are revised as resident condition changes.
Failure to Replace Broken Hearing Aids
Penalty
Summary
The facility failed to replace the broken hearing aids for one resident who had hearing loss and relied on hearing aids for communication. During a concurrent observation and interview, the resident stated being hard of hearing, needing people to speak loudly, and having hearing aids upon admission in September 2023 that were broken. The resident also stated informing Social Services about the need to replace the hearing aid. Records reviewed showed hearing loss in the H&P, hearing aids listed on the Inventory of Personal Effects form at admission, and hearing aids and glasses documented under Adaptive Aids in the Social History assessment. Audiology notes dated 8/6/25 indicated hearing abnormal by observation and that the resident complained of hearing problems. A CNA confirmed the resident had hearing difficulties for the last seven months and had reported the issue to the LVN. The MDS Director confirmed section B of the MDS was not accurately assessed, and the DON confirmed the resident's needs for hearing aid had not been addressed. The facility policy on Effective Communication stated staff will help residents who have lost or damaged hearing devices obtain services to replace them as indicated.
Failure to Assist Resident With Hearing Aid Replacement
Penalty
Summary
The facility failed to assist Resident 68 in obtaining replacement hearing aids after the resident reported that the hearing aids brought on admission were broken. During observation and interview, Resident 68 stated having hard of hearing and needing people to speak loudly to hear them, and said the hearing aids had been broken since admission and that Social Services had been informed about the need for replacement. The resident’s records showed a history of hearing loss, and the inventory of personal effects documented right and left hearing aids on admission. Social history also noted that the resident used hearing aids and glasses. Additional record review and staff interviews showed ongoing hearing difficulty. Audiology notes indicated hearing abnormal by observation, and a CNA confirmed the resident had hearing difficulties for the last seven months and had reported them to the LVN. Social Services reviewed the audiology notes and stated the resident had been examined by an audiologist and an audiogram was recommended, and that they would follow up on the recommendation and the need for hearing aid replacement. The DON confirmed that the resident’s hearing aid needs had not been addressed. The facility policy on Effective Communication stated staff will help residents who have lost or damaged hearing devices obtain services to replace them as indicated.
Failure to Provide Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to ensure continuous oxygen therapy was administered in accordance with a physician's order for one resident who had diagnoses including acute respiratory failure with hypoxia and hypertension. During observation, the resident was in bed, awake, and an oxygen concentrator was noted at the bedside but turned off. The resident's order required continuous oxygen at 2 LPM via nasal cannula or mask to keep oxygen saturation above 88% for COPD, and the order remained in place at the time of the observation. During interviews, the LVN stated the resident's oxygen was supposed to be administered continuously and later confirmed that oxygen was not continuously administered as ordered. The RN reviewed the order and stated that failure to administer oxygen as prescribed could worsen the resident's respiratory condition and lead to an altered level of consciousness. The DON also confirmed that oxygen was not continuously administered as ordered and stated the physician was contacted, resulting in the oxygen order being changed from continuous to as needed.
Delayed e-Kit Replacement and Incomplete Usage Documentation
Penalty
Summary
The facility failed to replace e-Kits in a timely manner and failed to accurately complete the e-Kit Usage Slip form. During a concurrent e-Kits inspection and interview, multiple e-Kits secured with black-colored zip ties were observed, and RN 5 stated that this indicated a medication had been signed out and used for a resident. RN 5 explained that licensed staff were to notify the pharmacy after a medication was used from an e-Kit, complete an e-Kit Usage Slip form, and leave a copy in the e-Kit. RN 5 also stated that e-Kits are usually replaced by the pharmacy within 72 hours of use. Review of the e-Kit Usage Slip forms showed lorazepam 0.5 mg was signed out for one resident, a 1300-30 mg tablet medication was signed out for another resident and later verified by RN 5 as acetaminophen with codeine, potassium chloride 10 mEq was signed out with no resident name written on the form, and two tablets of potassium chloride 10 mEq were signed out for another resident. RN 5 acknowledged that the usage slip needed to be completed properly, including the resident's name and medication name. The DON stated that e-Kits needed to be replaced promptly and verified that the e-Kits used from 8/13/25 to 8/22/25 already needed replacement kits from the pharmacy. The facility was unable to provide specific P&P addressing emergency supply replacement for controlled and non-controlled oral medications.
Unsafe Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored in a safe manner when loose tablets were found at the bottom of a medication cart drawer during an inspection with LVN 5. Three unidentified tablets were observed: one round white tablet, one round pink tablet, and one round orange tablet. LVN 5 was unable to identify the medications and stated they should have been discarded into the appropriate bin if they were not administered. The facility also failed to remove an expired tube of Silvasorb gel from a medication room, where it was observed with an expiration date of 6/2025 during an inspection with RN 2. In addition, cleaning products were stored in the same compartments as oral medications in a medication cart and as topical medications in a treatment cart. LVN 5 and TN 1 both verified the cleaning products were stored with medications and stated they should have been separated. The DON later acknowledged that expired medications that had already been removed from bubble packs and not given to residents should have been discarded, and that cleaning solutions should have been kept in a separate compartment from medications.
Survey Results Binder Not Clearly Posted
Penalty
Summary
The facility failed to ensure that eight of 11 sampled residents (Residents 196, 83, 116, 34, 11, 146, 92, and 62) knew the location of the nursing home's survey results binder. During an interview on 8/25/25 at 1:50 PM at the resident council meeting, eight of 11 residents polled did not know where the survey results binder was located. During a concurrent observation outside the activities/dining room and interview with the DON and ADM on 8/25/25 at 4:37 PM, the DON and ADM verified the binder's location and confirmed there were no signs at that location or anywhere else in the facility indicating where to find it.
Insufficient Room Space in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide a minimum of 80 square feet of livable space per resident in five of 77 resident rooms. During the entrance conference, the Administrator stated that the facility had resident rooms with less than the required square footage. During the environmental tour with the Maintenance Services Director, five resident rooms were observed to be under 80 square feet per resident. Each of the five rooms was a 3-bed room measuring about 223 to 223.54 square feet total, which calculated to 74.3 to 74.5 square feet per resident. The rooms were not crowded and did not impose any safety hazards, and there were no complaints from the residents occupying these rooms. The Administrator later confirmed that five of 77 resident rooms did not meet the required 80 square feet per resident requirement.
Failure to Provide Timely Dental Assessment
Penalty
Summary
The facility failed to provide a dental assessment to a resident within ninety days of admission, as required by its own policy. The resident, who was admitted with multiple diagnoses including intervertebral disc degeneration, type 2 diabetes mellitus, muscle wasting and atrophy, obstructive and reflux uropathy, acute kidney failure, and hypertension, did not receive any dental services after admission. This was confirmed through interviews with both the resident and the Director of Nursing (DON), as well as a review of the resident's admission record. The DON acknowledged that the resident should have been seen by the facility's dental consultant within ninety days of admission, in accordance with the facility's policy dated April 2007. The policy specifically states that a consultant dentist is responsible for providing a dental assessment to each resident within this timeframe. The lack of a dental assessment for this resident was verified through record review and staff interviews.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to report a suspected case of abuse involving a resident who was noted to have blanchable redness on the left side of the face near the left eye. The incident occurred after the resident's wife reported that the resident complained about the water being too hot during a shower given by a CNA, and that the resident's face was scrubbed too hard. The Licensed Vocational Nurse (LVN 1) received this complaint and reported it to the Front Desk LVN (LVN 2) and the Registered Nurse (RN 1). The RN conducted an assessment and confirmed the redness but deemed it blanchable. Despite the complaint and the physical evidence, the Director of Nursing (DON) and the Administrator did not report the incident to the California Department of Public Health (CDPH), as they did not perceive it as abuse due to a lack of malicious intent. The facility's policy requires all reports of resident abuse, including injuries of unknown origin, to be reported to local, state, and federal agencies. However, the facility's Interdisciplinary Team (IDT) reviewed the incident and concluded there was no intent to harm, thus deciding not to report it. The IDT's review included interviews with staff involved in the resident's care, but neither the resident nor the resident's wife was included in the meeting. The Administrator confirmed that the decision not to report was based on the belief that no abuse occurred, despite the facility's policy and procedure requirements.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain an accurate medication administration record (MAR) for a resident diagnosed with liver failure and end-stage renal disease (ESRD). On January 25, 2025, at 9:00 PM, a Licensed Vocational Nurse (LVN) did not sign the MAR to confirm the administration of Lactulose, a medication prescribed to reduce ammonia levels in the blood. The resident's orders specified that Lactulose should be administered orally three times a day, but the MAR only showed administration at 9:00 AM and 1:00 PM on that day. During interviews, the Director of Nursing (DON) confirmed that if a medication is not signed on the MAR, it is considered not given. The LVN involved stated that she believed she administered the medication but acknowledged her mistake in not signing the MAR. The facility's policy requires the individual administering medication to initial the MAR after giving each medication. This oversight potentially resulted in the resident's readmission to the hospital with elevated ammonia levels.
Failure to Document Foley Catheter Monitoring
Penalty
Summary
The facility failed to ensure that a resident with a foley catheter had documented monitoring per shift as ordered. This deficiency was identified during a review of the resident's medical records, which revealed missing electronic signatures for catheter monitoring on multiple shifts. The resident, who had a history of hemiplegia, epilepsy, chronic obstructive pulmonary disease, and urinary tract infections, was admitted to the facility with specific orders to monitor the catheter for changes in urine character and proper placement every shift. However, there were missing signatures from both the PM and NOC shifts, indicating a lack of documentation for the required monitoring. The deficiency was further highlighted when the resident experienced a change in condition, including tachycardia and altered level of consciousness, leading to a doctor's order to send the resident to an acute hospital for further evaluation. Interviews with the Assistant Director of Nursing and a Licensed Vocational Nurse revealed that the missing documentation was identified after an Ombudsman request, and the nurses attested to performing the assessments but failed to document them timely. The facility's policies on charting and documentation emphasize the importance of accurate and timely record-keeping, which was not adhered to in this case.
Failure to Respond to Call Lights and Provide ADLs
Penalty
Summary
The facility failed to adhere to its policy and procedure for providing Activities of Daily Living Services (ADLs) and ensuring timely response to call lights for two of the three sampled residents. Resident 1, who was admitted with chronic respiratory failure, morbid obesity, heart failure, and muscle wasting and atrophy, reported that staff took a long time to respond to call lights when assistance was needed. Similarly, Resident 3, with diagnoses including respiratory failure, type 2 diabetes mellitus, epilepsy, and muscle wasting and atrophy, also expressed that there were delays in answering call lights. The facility's policy, titled 'Answering the Call Light,' mandates that call lights should be answered as soon as possible, and the policy on 'Activities of Daily Living' requires that residents receive appropriate care to maintain or improve their abilities unless clinical conditions make it unavoidable. Interviews with the Administrator and the Director of Nursing confirmed that staff did not follow these policies, as they acknowledged the expectation for staff to respond to call lights and attend to residents' needs promptly.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide appropriate care to prevent the development of pressure ulcers in a resident, leading to a stage 4 pressure injury on the coccyx and multiple blisters on various parts of the body. The resident, who was admitted without any wounds, developed these injuries while under the facility's care. The resident had a high risk for skin breakdown due to decreased mobility, anemia, and other health conditions, as indicated in the care plan initiated upon admission. Despite the implementation of interventions such as applying protective lotion, using a pressure-reducing mattress, and providing frequent skin care, the resident developed a coccyx wound and heel blister shortly after admission. The facility's records show that the resident's skin was intact upon admission, but a comprehensive skin evaluation later revealed significant skin breakdown, including a stage 4 pressure injury and other blisters. The facility's policy on pressure ulcer prevention was not effectively followed, as the resident's condition deteriorated, leading to the development of multiple wounds. Interviews with the facility's staff, including the Treatment Nurse, ADON, and DON, confirmed that the resident did not have wounds upon admission and that the wounds developed during the resident's stay. The staff acknowledged the resident's poor circulation and immunocompromised state but indicated that the wounds could have been prevented. The facility's failure to adhere to its own policies and procedures for pressure ulcer prevention contributed to the resident's skin breakdown and subsequent transfer to a hospital for further evaluation.
Delayed Response to Call Lights for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely response to call lights, impacting two residents. Resident 1, who was admitted with cerebral ataxia and hypothyroidism, expressed dissatisfaction with the response time to call lights, particularly during the PM shift after 9:00 PM. The resident reported waiting for assistance for up to two hours. Resident 1's care plan indicated a need for prompt response to call lights due to deficits in activities of daily living related to their medical conditions. Similarly, Resident 2, admitted with heart failure, also reported excessive delays in response to call lights, sometimes resorting to using a telephone to contact the desk for quicker assistance. Resident 2 experienced delays while soiled, with response times extending up to two hours. The care plan for Resident 2 highlighted the need for assistance with activities of daily living due to mobility decline. The facility's policy, revised in October 2010, emphasized the importance of responding to residents' requests and needs promptly.
Resident Discharged with Incorrect Medications
Penalty
Summary
The facility failed to ensure that a resident was discharged home with the correct medication packs as ordered by the physician. This failure resulted in the resident being discharged with four medication packs that were not prescribed to them and belonged to another resident. The resident had been admitted with diagnoses including heart failure, hypothyroidism, and acute kidney failure. During the review of the resident's medical records, it was found that the post-discharge plan of care did not match the medication orders, and a critical medication for hypothyroidism was missing. The Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) acknowledged the discrepancy and confirmed that the resident received another resident's medication packs, which should not have happened. The normal discharge process involves explaining the medications to the resident or their responsible party, checking the medication list against the resident's wristband, and having multiple nurses verify the medications. However, in this case, the process was not followed correctly. The Director of Nursing (DON) also confirmed that the medications should be verified against the physician's orders and that the resident should agree with the medications and sign off on them. The facility's policy on discharge medications requires reconciliation of pre-discharge and post-discharge medications, which was not adhered to in this instance.
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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 Ontario
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ontario Grove Healthcare & Wellness Centre, Lp | 0.3 mi | ★★★★★ | 1 | 0 |
| Heritage Park Nursing Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Upland Rehabilitation And Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Villa Mesa Care Center | 1.5 mi | ★★★★★ | 19 | 0 |
| Ontario Healthcare Center | 2.7 mi | ★★★★★ | 12 | 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.