Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Leisure Court Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure psychotropic medications were used with required documentation and monitoring. Several residents receiving antipsychotics had inaccurate orthostatic BP records showing the same readings for lying and sitting positions, and behavior monitoring records lacked documentation of non-pharmacological interventions. One resident’s Remeron dose increase lacked a documented physician rationale, and two residents had PRN benzodiazepine orders extended beyond 14 days without the prescriber’s rationale in the record.
Respiratory care was not provided as ordered for three residents. One resident’s nasal cannula tubing and storage bag were not changed weekly, another resident received oxygen at a higher LPM than ordered and had undated, unlabeled tubing with no oxygen-in-use sign posted, and a third resident had undated, unlabeled oxygen tubing with no documented MD order for oxygen therapy.
Kitchen sanitation deficiencies were identified when five cutting boards were observed with fuzzy, heavily marred grooves and food items in the walk-in refrigerator were found past their used-by dates. The DSS verified the findings, and facility records showed 97 of 105 residents were receiving food prepared in the kitchen.
The facility failed to carry out its infection control program accurately when surveillance forms and monthly logs for multiple residents did not match McGeer criteria, included blank vital signs and missing criteria, or used the wrong surveillance tool. The facility also did not have a documented Legionella water management program in the binder, despite its policy and risk assessment, and Treatment Cart 1 contained paperwork instead of only treatment items, contrary to staff statements and facility policy.
Antibiotic Stewardship Monitoring Failure: The facility failed to accurately monitor and classify antibiotic use for several residents. A resident review showed antimicrobial therapy was given even though the infections did not meet McGeer’s criteria for true infection, and the surveillance forms did not identify the cases as DNMC. The IP stated he was responsible for reviewing the criteria and determining whether infections were HAI, CAI, or DNMC, and the DON acknowledged the findings.
Incomplete and Unrenewed Informed Consent for Psychotropic Medications: The facility failed to keep informed consent current for psychotropic meds for two residents. One resident’s consents for buspirone and quetiapine were not renewed after the required six-month interval, and another resident’s Restoril consent forms had blank prescriber signature fields despite repeated use of the medication. RN and DON verified the missing renewal and signature issues during record review.
A resident's call light was not kept within reach. During an observation, the call light button was found hanging behind the resident on the headboard, and the resident said he could not locate it. An RN confirmed the button was out of reach, despite facility policy requiring call lights to be within easy reach when a resident is in bed.
A resident who was cognitively intact indicated a wish to execute an advance directive, but the medical record did not show that social services assisted with completing the document or documented any such assistance. The facility policy required referral to social services and coordination with the Ombudsman, and both the Social Services Assistant and DON acknowledged that the resident should have been assisted and that the effort should have been documented.
A resident was observed in a wheelchair with a pommel cushion in use, but the record did not show a physician order, informed consent, or care plan for the device. RN and CNA interviews confirmed the cushion was being used to prevent the resident from sliding down in the wheelchair, and the DON verified the findings.
The facility failed to incorporate PASRR Level II recommendations into the care plans for two residents. One resident had bipolar disorder and moderately impaired cognition, and the PASRR determination listed multiple specialized services, but the care plan did not reflect those needs. Another resident’s PASRR Level II mental health evaluation recommended specialized services such as MH rehab activities, ADL training, psychotherapy, neuropsychology, psychiatry, safety monitors, pharmacy, and pain services consultations, but the plan of care did not address the PASRR determination.
A resident was observed in a wheelchair with a pommel cushion in place, but the resident's care plan did not address its use. RN and CNA staff verified the cushion was used to prevent sliding, and the DON confirmed there was no physician order, consent, or care plan for the intervention. The resident had no capacity to understand or make decisions and was totally dependent on staff for ADLs.
A resident with ESRD on hemodialysis had a care plan for dialysis/renal failure that was not revised to include the correct dialysis access site or the physician-ordered 1500 mL/day fluid restriction. The MAR showed orders for a right anterior chest tunnel dialysis catheter and related pressure dressing care, and an LVN and the DON verified the care plan did not reflect these current needs.
A facility failed to follow insulin injection site rotation orders for two residents, with MAR review showing repeated insulin administrations in the same abdominal area and an LPN/RN confirming the sites were not always rotated. The facility also failed to document, monitor, or care plan a resident’s unexplained purplish left forearm skin discoloration; the resident was observed with the discoloration, and staff confirmed there was no MD order or care plan addressing it.
Failure to Keep APP Mattress Connected and Functioning: A resident who was totally dependent for mobility and ordered to use an APP mattress for skin prevention was observed with the APP device turned on but the tubing disconnected from the mattress on multiple occasions. The mattress was not inflated, and RNs verified the findings. The resident had a care plan for skin breaks/pressure ulcer risk and a physician order to check the APP mattress every shift and monitor it daily.
A resident with impaired decision-making had a left hand splint order for ROM maintenance, but the care plan did not include skin assessment interventions tied to splint use. Staff documented splint application and removal times, yet there was no documented evidence of the required skin checks while the splint was in place, and the DON acknowledged the deficiency.
A facility failed to obtain ordered weekly weights and failed to document RD evaluations for two residents with significant weight loss. One resident had a seven-pound loss in one month and enteral feeding orders, but the record lacked the ordered weekly weight and RD assessment documentation. Another resident had progressive weight loss over several weeks, but the record lacked the ordered weekly weight and RD evaluation. The DON verified the missing documentation.
A resident with ESRD and dialysis access sites on the left arm and right upper chest did not receive required dialysis-related care. Staff documented multiple BPs on the left arm despite the AV shunt location, the record lacked orders for no BP or venipuncture to that arm, and an RN verified that emergency dialysis kit supplies were not kept at the bedside even though the resident was considered high risk for bleeding.
The facility failed to maintain proper controlled medication accountability when an Ativan dose was removed from a bubble pack but not documented as wasted with a second licensed nurse witness, and it failed to clarify a famotidine order that listed an inappropriate indication of “supplement.” The DON verified both issues during record review and stated the expectation was for controlled waste to be witnessed and for each medication order to have an appropriate indication.
Unlabeled medication items were found in two medication carts, including an opened bottle of artificial tears and inhaler mouthpieces for two residents, and the IP and RN confirmed the missing resident-specific labels. The Central Supply Room also lacked current temperature documentation despite stored meds with specific temperature requirements. In addition, a medication cup containing zinc oxide was left unattended at a resident’s bedside, and an LPN initially discarded it in regular trash before retrieving it; the resident had no order for self-administration and was unable to self-administer.
Menu Not Followed for Two Residents on Pureed Diets: Two residents on ordered pureed diets were not served the cappuccino mousse dessert listed on the lunch menu and on the facility’s pureed menu. During the meal observation, both residents received other pureed items and supplements, but the dessert was not observed on either tray. The IP verified the omission, and the DON acknowledged the findings.
A resident’s H&P and repeated physician progress notes incorrectly documented admission to a different facility name instead of the actual LTC facility. The MRD verified the inaccurate record entries, and the DON confirmed the MD was aware of the incorrect admitting-facility documentation.
A resident’s MDS was not coded accurately for left hand splint assistance. The physician ordered the splint to be applied to the left hand 5 times weekly or as tolerated, and restorative nursing documentation showed the splint was applied for 4 hours on multiple days, but the MDS coded the resident for none or less than 15 minutes per day. The DON reviewed the record and verified the finding.
A resident with schizoaffective disorder, depression, and diabetes mellitus left through a secured front door after entering the keypad code and propelling herself out in a wheelchair. Staff did not recognize her as a high elopement risk despite a high-risk score, and her care plan did not address elopement. She was later found in an ED about 50 miles away with disorganized behavior, hallucinations, and acute psychosis, and was placed on a 5150 hold.
Two residents with cognitive impairment were involved in an altercation when one resident attempted to enter another resident’s room, leading the room’s occupant to push the other in the chest, causing a fall and subsequent hip and pelvic fractures. Prior to the incident, the injured resident ambulated with supervision and required only set-up or minimal assistance for bed mobility and transfers, but afterward required partial to maximal assistance, used a two-wheeled walker, and experienced significant pain with frequent crying, screaming, and yelling. Staff, including CNAs and LPNs, reported that the resident became largely bedbound and dependent for ADLs following the event. The facility had an abuse prevention and reporting policy defining abuse as willful infliction of injury or intimidation resulting in harm, yet the incident demonstrated a failure to protect a resident from physical abuse by another resident.
Two residents were involved in an altercation when one cognitively impaired resident pushed another who was attempting to enter her room, causing the second resident to fall, cry, and complain of left hip pain, later associated with pubic rami fractures. Staff, including an LVN and an RN, were informed of the push on the same day, and the pushing resident admitted to giving a shove. Facility policy required that allegations of physical abuse and resident-to-resident altercations with actual harm be reported to CDPH, the ombudsman, and local law enforcement within 2 hours, but the RN did not make these notifications within the required timeframe. Instead, the SOC 341 abuse report naming one resident as the victim and the other as the alleged abuser was submitted the next day, outside the mandated reporting window.
A resident with impaired decision-making capacity experienced an unwitnessed fall, cried and pointed to the hip, and reported moderate pain. An x‑ray later showed fractures of the left superior and inferior pubic rami, but nursing staff only faxed the abnormal radiology report and did not call the MD as required by facility policy. The resident had PRN acetaminophen ordered for mild pain and a Lidoderm patch ordered for hip pain, yet acetaminophen was repeatedly administered for pain scores above the mild range without notifying the MD. Required pain documentation, including a pain flow sheet and consistent recording of responses and non‑pharmacologic interventions, was missing from the record, and staff could not recall whether pain medication was given immediately after the fall.
The facility failed to maintain sanitary conditions in the kitchen, including improper use of cutting boards for raw poultry, inadequate sanitizing solution concentration, and unclean kitchen equipment. Additionally, utensils were not air-dried, and maintenance tools were improperly stored, posing contamination risks. These issues were confirmed by staff and management.
A resident was found to be self-administering Flax Seed Oil and Omegas + Tumeric supplements without a physician's order or an assessment by the IDT. Despite being cognitively intact, the resident's medical records lacked documentation of an assessment or care plan for self-administration. The facility's policy required such assessments and physician approval, which were not conducted.
A resident with a positive Level I PASRR screening for serious mental illness did not receive a required Level II mental health evaluation after being admitted to the facility. The facility failed to notify the California Department of Health Care Services Level II evaluators of the resident's admission, and no documentation was found to indicate awareness of the resident's status.
The facility failed to ensure proper PASRR screenings for two residents, as the Business Office Manager, not a qualified staff member, completed the screenings. Additionally, the facility did not follow up with DHCS when one resident's screening was closed due to unresponsiveness, risking inadequate services for the residents' mental disorders.
A resident with a forearm wound did not receive a scheduled dermatology consult due to a transportation error. The facility failed to reschedule the appointment or document follow-up actions, resulting in a deficiency in providing necessary services as ordered by the physician.
A resident with severe cognitive impairment and mobility issues did not receive the necessary restorative nursing services as ordered. The facility failed to apply carrot splints to the resident's hands and AFOs to the feet for the required duration, as per physician's orders. Observations showed the resident with contracted hands and rolled towels instead of splints, and documentation lacked evidence of the required application time.
A facility failed to document and address the elopement risk for a resident who exhibited wandering and exit-seeking behaviors. Despite staff observations of the resident's desire to leave and standing by the locked front door, the resident was not assessed as high risk for elopement, and there was no documentation of these behaviors or interventions in the medical record. Additionally, the resident was not provided with an ID bracelet as per the elopement assessment plan, and there was no care plan for the resident's non-compliance with wearing the bracelet.
A facility failed to update a resident's gastrostomy tube (GT) feeding rate and care plan according to the physician's orders. The resident's GT feeding was observed running at 60 ml/hr, despite an order to increase it to 65 ml/hr. This discrepancy was confirmed by an LVN, who acknowledged the incorrect rate and conflicting orders. The care plan also did not reflect the updated feeding rate, posing a risk to the resident's care.
A facility failed to monitor a resident's vital signs and weight after dialysis sessions on multiple occasions, as required by their policies. This oversight was confirmed through medical record reviews and an interview with an RN, highlighting a lack of documentation and follow-up with the dialysis facility.
A resident with morbid obesity was using side rails without a physician's order or informed consent, and the facility did not attempt less restrictive alternatives or develop a care plan. Staff confirmed the lack of necessary documentation and procedures, which was acknowledged by the DON.
The facility failed to administer medications as ordered and accurately document them for two residents. One resident did not receive a prescribed medication, and the MAR was inaccurately completed. Another resident's controlled medication was not documented in the MAR after administration. Additionally, narcotic inventory checks were not properly conducted, with missing signatures on the Narcotic Check Sheet.
The facility failed to ensure two residents were free from unnecessary drugs, leading to potential adverse effects. One resident was given metoprolol and clonidine despite low blood pressure readings, while another was administered metoprolol below the prescribed threshold. These actions were confirmed by RNs during interviews and medical record reviews.
The facility failed to ensure seven residents were free from unnecessary psychotropic drugs, with deficiencies in monitoring, informed consent, and documentation. Inconsistent meal intake monitoring, lack of renewed informed consents, and failure to monitor side effects were noted. These issues could lead to adverse complications and inadequate data for prescribers.
A resident did not receive their prescribed Zyprexa medication for several days due to a delay in pharmacy order transmission and delivery. The MAR was inaccurately signed, indicating administration when the medication was not available. The facility's policies for medication administration and order transmission were not followed, leading to a significant medication error.
The facility failed to ensure proper medication storage in two instances. Medication Cart A contained both orally and externally administered medications in the same compartment, confirmed by an LVN. Additionally, Medication Cart B was left unlocked and unattended in a hallway, as verified by the DON and an LVN. These lapses could negatively impact residents' well-being and increase the risk of drug diversion or misuse.
The facility failed to ensure kitchen staff competency in food safety practices, including testing sanitizing solutions and using correct cutting boards. Two dietary aides were unable to correctly test sanitizing solutions, and a cook used the wrong cutting board for raw poultry. The CDM admitted to not providing necessary in-service training, posing a risk of unsafe food handling for 94 residents.
The facility failed to provide adequate protein in vegetarian meals for two residents, one with vitamin D deficiency and hypocalcemia, and another with severe protein-calorie malnutrition and pulmonary disease. The residents received grilled cheese sandwiches with insufficient protein compared to the regular menu. The facility lacked a structured vegetarian menu and portion guidelines, leading to this nutritional deficiency.
The facility failed to ensure proper storage, preparation, and safe food handling for food brought in by visitors, risking foodborne illness for 94 residents. Staff interviews revealed inconsistencies in policy implementation, with food being stored and reheated contrary to guidelines. No recent staff training or visitor education on safe food handling was evident, contributing to the deficiency.
A facility failed to provide necessary hospice care for a resident with senile degeneration of the brain, as required by physician orders. The resident did not receive the prescribed number of visits from a Certified Home Health Aide and a Skilled Nurse over several weeks. Additionally, the facility lacked a designated hospice coordinator, leading to communication delays between the hospice provider and the facility, potentially affecting the resident's care.
The facility failed to maintain infection control in the laundry room and medication carts. Personal belongings were found in the clean folding area, risking contamination of linens. Additionally, spoon containers on Medication Carts B and C were dirty and damaged, compromising infection control during medication administration.
The facility failed to maintain essential equipment, including improper cleaning of the ice machine, a charred microwave, and ice buildup in medication and specimen refrigerators. The Maintenance Director admitted to not following manufacturer's guidelines for the ice machine, and the unsafe microwave was removed after being reported. These deficiencies were confirmed by staff, including the DON and Infection Preventionist.
The facility failed to complete entrapment assessments and record measurements during bed inspections for residents using side rails, impacting four residents. The facility's policies required regular inspections to prevent risks, but these were not followed. For example, a resident using side rails for mobility had no documented entrapment assessment, and another resident's assessment was incomplete. The Environmental Services Director confirmed these findings, acknowledging incomplete documentation and assessments.
The facility failed to maintain a homelike environment for two residents due to scratches and unpainted areas on the walls adjacent to their beds. One resident expressed a desire for the wall to be repaired and painted, while another resident, who spent most of her time in her room, also requested repairs. These observations were communicated to the Administrator.
A facility failed to notify the Ombudsman of a resident's discharge, as required by policy. The resident, admitted for short-term respite care, was discharged after one day due to aggressive behavior. Despite attempts by RN 2 to fax the notice, it was not found in the medical record, and the Ombudsman did not receive it, risking the resident's awareness of appeal rights.
Unnecessary Psychotropic Medication Use and Incomplete Monitoring Documentation
Penalty
Summary
The facility failed to ensure several residents were free from unnecessary psychotropic medication use and failed to follow ordered monitoring and documentation requirements tied to those medications. The report identified deficiencies involving residents receiving quetiapine, risperidone, escitalopram, Remeron, Restoril, and Ativan, with concerns centered on inaccurate orthostatic blood pressure monitoring, missing documentation of non-pharmacological interventions for targeted behaviors, and missing physician rationale for extending PRN benzodiazepine orders beyond 14 days. For Resident 38, who could make needs known but could not make medical decisions, the record showed quetiapine ordered along with weekly orthostatic blood pressure monitoring and monitoring of scratching episodes every shift. The documented lying and sitting blood pressures were the same on the dates reviewed, and the record did not show documented non-pharmacological interventions for the scratching episodes. RN verification confirmed the blood pressure readings were recorded the same for both positions and that no documented evidence of interventions for scratching was present. Similar inaccurate orthostatic blood pressure documentation was found for Resident 52, Resident 9, Resident 10, and Resident 4, all of whom had quetiapine or other antipsychotic orders with orthostatic monitoring requirements. Resident 7 had Remeron increased from 7.5 mg to 15 mg at bedtime for depression manifested by poor meal intake, but the physician progress note did not document a rationale for the dose increase. Resident 4 also had orders for quetiapine, risperidone, and escitalopram with behavior monitoring for crying, angry outbursts, and striking out, but the record did not show documented non-pharmacological interventions for the observed behaviors. For Residents 80 and 83, the record showed PRN benzodiazepine orders that extended beyond 14 days, but the medical record did not contain documentation of the prescribing practitioner’s rationale for extending those PRN psychotropic orders.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents receiving oxygen therapy. For one resident, the nasal cannula tubing and storage bag were not changed every seven days as required by facility policy. For another resident, oxygen was being administered continuously at 3.5 LPM even though the physician’s order was for 2 LPM, the nasal cannula tubing was undated and unlabeled, and there was no oxygen-in-use sign posted outside the room. For a third resident, oxygen tubing was observed unlabeled and undated, and the medical record did not show a physician’s order for oxygen administration. Resident 41 was observed in bed receiving oxygen at 2 LPM via nasal cannula attached to an oxygen concentrator. The resident’s order summary showed an order to replace the nasal cannula every Sunday on day shift. During observation and record review with an RN, the RN verified the nasal cannula should have been changed every seven days for infection control. The facility’s policy stated disposable tubing and cannulas were to be used for residents receiving oxygen and that cannulas should be replaced weekly. Resident 67 was observed receiving continuous oxygen therapy via nasal cannula, and the tubing was undated and unlabeled. The oxygen-in-use sign was not observed outside the room. The resident’s order summary showed orders for continuous oxygen at 2 LPM via nasal cannula and for the nasal cannula to be replaced every Sunday. The DON verified the resident was receiving 3.5 LPM of continuous oxygen, acknowledged the tubing was undated, and confirmed there was no oxygen-in-use sign outside the room. Resident 109 was also observed receiving oxygen via nasal cannula with tubing that was unlabeled and undated, and review of the medical record showed no documented physician’s order for oxygen therapy.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen. During an initial tour of the kitchen with the DSS, five cutting boards were observed with fuzzy and heavily marred grooves. The DSS verified that the cutting boards should have been replaced because the damaged cutting surfaces were not kept in a sanitary condition and did not have a cleanable surface. During the same kitchen observation, the walk-in refrigerator contained a plastic storage container of zucchini with a used-by date of 6/12/26 and a plastic storage container of butter/margarine with a used-by date of 6/14/26. The DSS verified that both items should have been discarded. Facility records showed 97 of 105 residents were receiving food prepared in the kitchen, and the Assistant Administrator, DSS, and DON were informed and acknowledged the findings.
Infection Surveillance, Water Management, and Treatment Cart Storage Failures
Penalty
Summary
The facility failed to implement its infection prevention and control program in accordance with its policies and procedures. Review of monthly infection surveillance logs from January 2026 through May 2026 showed counts for HAI, CAI, and DNMC, but review of the Surveillance Data Collection Forms for Residents 2, 21, 37, 52, 71, 93, and 112 showed that the documentation used to determine whether infections met McGeer’s criteria was incomplete or incorrect. Several forms had blank vital signs and missing onset dates, some forms did not have all required criteria selected, and some residents were tracked using the wrong surveillance tool. The IP stated he was responsible for surveillance and for determining whether infections were HAI, CAI, or DNMC, and later verified that the classifications for Residents 2, 21, 37, 52, and 112 were incorrect. For Resident 93, the respiratory infection form showed new or increased cough and sputum production, but temperature, pulse, respirations, chest radiograph findings, and constitutional criteria were blank or not selected; the monthly log documented the infection as HAI, common cold/pharyngitis. For Resident 2, the pneumonia form had blank onset date and vital signs, none of the pneumonia criteria were selected, yet the resident was receiving levofloxacin and the log documented pneumonia as CAI. For Resident 71, the form used was for other infections, with blank temperature and pulse, and the log documented a urinary tract infection and DNMC even though a urinary tract infection surveillance tool was not used. For Resident 112, the urinary tract infection form showed only one criterion selected, with blank vital signs, yet the log documented CAI. For Resident 21, the pneumonia form had blank vital signs and only one criterion selected, while the log documented pneumonia as CAI. For Resident 52, the urinary tract infection form had blank vital signs and no criteria selected, yet the log documented CAI. For Resident 37, the pneumonia form had blank vital signs and only one respiratory subcriterion selected, and the log documented CAI. The facility also failed to have an available water management program for Legionella and other opportunistic waterborne pathogens. The facility’s policy stated that a Water Management Program would be developed and reviewed annually, and a Legionella risk assessment showed the facility should have such a program for the hot and cold-water distribution systems. However, review of the water management binder did not show documented evidence of a Water Management Program with testing protocols, acceptable control ranges, or corrective actions when limits were not maintained. The DON and IP stated the water management documents were kept in the binder, but they verified that the program was not present, and the DON acknowledged the facility had not developed a Water Management Program. The facility also failed to keep Treatment Cart 1 in sanitary condition when multiple pieces of paperwork were stored inside it. On observation, paperwork was found inside the cart, and the treatment nurse stated it had been stored there for several days. Other staff stated treatment paperwork should not be stored in the cart, the MRD verified facility records were not to be stored there, and the IP stated only treatment items such as medications were to be stored in the cart. The DON stated the paperwork should have been placed in a binder or folder and that the treatment cart should only store treatments.
Antibiotic Stewardship Monitoring Failure
Penalty
Summary
The facility failed to accurately monitor and address antibiotic use for Residents 2 and 52, as well as three nonsampled residents, Residents 21, 37, and 112, during review for antibiotic stewardship. These residents were prescribed antimicrobial therapy even though the facility’s review determined their infections did not meet McGeer’s criteria for true infection. The facility’s Infection Control, Antimicrobial Stewardship policy stated that the IP, DON, and/or pharmacy would report the number of antibiotics prescribed each month and include a separate report for residents on antibiotics who did not meet McGeer’s criteria for active infection. Review of the monthly Infection Prevention and Control Surveillance Logs from January 2026 through May 2026 showed counts for HAI, CAI, and DNMC, and the IP stated he was responsible for surveillance, reviewing McGeer’s criteria tools, and determining whether infections were HAI, CAI, or DNMC. After reviewing the Surveillance Data Collection Forms and medical records for Residents 2, 21, 37, 52, and 112, the IP verified that the infections did not meet McGeer’s criteria, the residents completed antimicrobial therapy, and the forms did not indicate DNMC. The DON stated that the determination of true infection and the classification of HAI, CAI, and DNMC should be accurately determined and reported, and acknowledged the findings.
Incomplete and Unrenewed Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents or their representatives were informed in advance of proposed psychotropic medication treatment for two residents reviewed for unnecessary medications. For Resident 38, who was admitted and later readmitted to the facility and whose H&P stated the resident could make needs known but could not make medical decisions, the record showed orders for buspirone 5 mg twice daily and quetiapine 25 mg twice daily. The informed consent forms for both medications were signed by the physician on 11/30/25 and the resident/responsible party was informed on 12/10/25, but the facility did not renew the consents after six months as required by its policy. During the 6/17/26 interview and record review, RN 1 verified the consents for buspirone and quetiapine had not been renewed. For Resident 80, the record showed orders for Restoril 15 mg as needed for insomnia, with administration documented multiple times in April, May, and June 2026. The facility’s informed consent forms for Restoril dated 4/21, 5/8, and 6/5/26 had blank prescriber signature fields. During the 6/18/26 interview and concurrent record review, the DON verified the prescriber signature fields were blank on all three informed consent forms. The facility’s policy stated the attending physician, PA, or NP must obtain informed consent for psychotherapeutic medication, and the informed consent policy required renewal every six months.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to provide a reasonable accommodation for Resident 111 by not keeping the resident's call light within reach. Resident 111 was admitted to the facility and had an H&P dated 6/10/26 showing the resident had the capacity to understand and make decisions. During an initial tour on 6/15/26, the resident's call light button was observed hanging on the left side of the headboard behind the resident, and the resident stated he could not locate it. RN 2 was brought to the room and confirmed that the call light button was hanging on the left side of the headboard and that Resident 111 could not reach it. The facility policy stated that when a resident is in bed, staff should make sure the call light is within easy reach.
Failure to Assist Resident With Advance Directive
Penalty
Summary
The facility failed to ensure that Resident 68 was assisted with formulating an advance directive after the resident indicated a wish to execute one. The resident’s Advance Directive Acknowledgement form showed that he had not executed an advance directive and selected that he wished to do so, but the medical record did not contain a copy of an advance directive or documentation that assistance had been provided to complete one. Resident 68’s MDS assessment showed the resident was cognitively intact. The facility’s Advance Directives policy stated that residents requesting assistance in developing an advance directive should be referred to social services, and that social services staff would assist with completion of an advance directive and arrange for the Ombudsman to complete and witness the document. During interview, the Social Services Assistant verified that if a resident or responsible party wanted to formulate an advance directive, social services was responsible for coordinating with the Ombudsman and documenting the assistance in the medical record. The DON also stated that the resident should have been assisted as soon as possible and that any attempt to assist should have been documented, but the record for Resident 68 did not show that this occurred.
Pommel Cushion Used Without Order, Consent, or Care Plan
Penalty
Summary
The facility failed to implement restraint-free periods for one of 22 sampled residents, Resident 7, who was observed seated in a wheelchair with a pommel cushion in the activity room. Resident 7 was admitted to the facility and had an H&P examination dated 3/16/26 showing the resident had no capacity to understand and make decisions. Review of the facility's Physical Restraints policy showed that restraints are to be used only after other alternatives have been tried unsuccessfully and only after a thorough assessment, informed consent from the resident or responsible party, a physician's order, and a care plan addressing the restraint use. Medical record review for Resident 7's 6/2026 Order Summary Report did not show a physician's order for the pommel cushion in the wheelchair, and the record also did not show informed consent for its use before the device was applied. During interviews, CNA 1 verified the resident used the pommel cushion and was totally dependent on staff for all ADLs. RN 3 confirmed the pommel cushion was being used to prevent the resident from sliding down in the wheelchair and verified there was no physician's order, consent, or care plan for the device. The DON was also informed and verified these findings.
PASRR Level II recommendations not incorporated into care plans
Penalty
Summary
The facility failed to incorporate PASRR Level II recommendations into the assessment and care planning for two residents. For Resident 19, the initial PAS showed a Level 1 positive result and the Level II determination included multiple specialized add-on services, including mental health rehabilitation activities, ADL training/reinforcement, supportive services, psychotherapy/counseling, psychiatry consultation and follow-up care, safety monitors, pharmacy consultation, pain services consultation, ophthalmology consultation, PT, OT, speech therapy, dietary consultation, social services consultation, continence evaluation, and accessibility accommodations. The resident’s care plan dated 5/26/26 did not show an individualized care plan for the PASRR Level II recommendation. Resident 19’s record also showed a history of bipolar disorder and an MDS assessment with a BIMS summary score of 8, indicating moderately impaired cognition. During an interview and concurrent record review, the MDS Coordinator was unable to show a personalized care plan for the PASRR Level II recommendation from the DHCS psychologist. The Assistant Administrator and DON were informed of these findings and acknowledged them. For Resident 67, the PASRR Level II mental health evaluation identified recommended specialized services including mental health rehabilitation activities, ADL training/reinforcement, supportive services, psychotherapy, neuropsychology consultation, psychiatry consultation, safety monitors, pharmacy consultation, and pain services consultation. After the resident was readmitted, the facility’s plan of care records did not show a care plan problem addressing the PASRR Individualized Determination Report. RN 3 verified that a care plan had not been developed to address the PASRR recommendations, and the DON stated that the PASRR should be reviewed for accuracy and followed up if unable to complete.
Missing Care Plan for Wheelchair Pommel Cushion
Penalty
Summary
The facility failed to ensure a resident-centered comprehensive care plan was developed for Resident 7 regarding the use of a pommel cushion in the wheelchair. Facility policy stated the interdisciplinary team is responsible for developing an individualized resident-centered comprehensive care plan based on the resident's needs and comprehensive assessment, but review of Resident 7's plan of care did not show a care plan problem or documented interventions addressing the pommel cushion. Resident 7 was observed up in a wheelchair in the Activity Room with a pommel cushion on the seat. The resident's history and physical dated 3/16/26 showed the resident had no capacity to understand and make decisions. CNA 1 verified the resident used the pommel cushion and was totally dependent on staff for all ADLs. RN 3 verified the cushion was used to prevent the resident from sliding down the wheelchair and stated there was no physician's order, consent, or care plan for the use of the pommel cushion. The DON was informed and verified these findings.
Care Plan Not Updated for Dialysis Needs
Penalty
Summary
The facility failed to ensure the comprehensive plan of care for one of 22 sampled residents, Resident 2, was revised to reflect current care needs and interventions. Resident 2 was admitted with end stage renal disease (ESRD) and was receiving hemodialysis. The resident’s care plan included a dialysis/renal failure problem dated 4/22/26, but it did not document the correct dialysis access site or include the physician-ordered amount of fluid restriction. The medical record showed physician orders for a right anterior chest tunnel dialysis catheter, including pressure dressing care as needed for bleeding, removal of the pressure dressing after dialysis on Monday, Wednesday, and Friday evenings, and a fluid restriction of 1500 mL per day. During an interview and concurrent record review, LVN 2 verified the resident was on hemodialysis every Monday, Wednesday, and Friday and confirmed the care plan had not been revised to include the dialysis access site or the specific fluid restriction amount. The DON was later informed and verified these findings.
Failure to Rotate Insulin Injection Sites and Monitor Skin Discoloration
Penalty
Summary
The facility failed to provide the necessary services to attain or maintain the highest practicable well-being for three residents. For two residents, physician orders required insulin injections to be rotated, but the facility’s location-of-administration records showed repeated use of the same injection sites. For one resident, the facility also failed to monitor and care plan a purplish skin discoloration on the left forearm that was observed during an interview and examination. For one resident, the record showed orders for insulin glargine in the morning and Novolin R before meals and at bedtime, both with instructions to rotate injection sites. The May 2026 administration record showed Novolin R given multiple times in the same abdominal quadrant on several occasions. During interview and record review, an RN verified the orders and acknowledged that there were times the injection sites were not rotated when the insulin was administered. For another resident, the record showed orders for insulin aspart with meals and insulin glargine in the morning, with rotation of injection sites ordered for the glargine. The June 2026 administration record showed insulin aspart given consecutively in the same abdominal area and later in the left arm. For the resident with the skin discoloration, the resident was observed lying in bed with purplish discoloration on the left forearm and stated not knowing how it happened. The shower/body check sheet did not document the discoloration, there was no physician order to monitor it, and the care plan did not address it. Staff interviews confirmed there was no order and no care plan for the discoloration.
Failure to Keep APP Mattress Connected and Functioning
Penalty
Summary
The facility failed to ensure the necessary care and services were provided to prevent the development of a new pressure ulcer for one of two sampled residents reviewed for pressure ulcers. Resident 24 was admitted and later readmitted to the facility, had no capacity to understand and make decisions, and was totally dependent on staff for mobility activities including rolling, sitting, lying, and transfers. The resident had a physician order dated 4/10/26 for an alternating pressure pad (APP) mattress for skin prevention and management, with instructions to check the proper setting and function every shift and monitor every day. The resident also had a care plan problem dated 3/16/26 addressing risk for skin breaks and pressure ulcers, with interventions including a therapeutic mattress, repositioning, and use of the APP mattress. During the initial tour and subsequent observations, the APP device was seen turned on and hanging on the headboard, but the tubing was lying on the floor and not connected to the mattress pad under Resident 24. On multiple observations, the APP mattress was not inflated. RN 4 verified the findings and stated staff entering the room should check that the APP device was turned on and the mattress was inflated. RN 2 reviewed the record and verified the physician order and care plan interventions for the APP mattress. The DON stated the APP mattress was intended to provide comfort and prevent pressure injuries for residents at risk, and that all staff entering the room should check that the device and mattress were working properly.
Failure to Document Skin Checks With Splint Use
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided for Resident 11’s positioning and mobility needs when a left hand splint was used. Resident 11 was unable to make independent medical decisions and had a physician’s order for the RNA to apply the left hand splint five times a week for four hours, or as tolerated. The facility’s policy stated the splint should be applied correctly to maintain ROM and prevent contractures and further loss of ROM. Resident 11’s joint mobility care plan identified a risk for further joint contracture and included the splint program, but it did not include interventions to monitor the left hand for complications related to the splint or to perform skin checks when the splint was applied. The restorative nursing documentation showed repeated application and removal times for the splint, and RNA 1 stated the skin was checked every two hours when the splint was in use, but there was no documented evidence of those skin checks. RN 3 verified there was no physician order to assess the skin while the splint was applied and confirmed the care plan did not include skin assessment interventions related to splint use. The DON stated that when the splint was applied for more than two hours, staff should check the resident’s skin every two hours and document it, and acknowledged the findings.
Failure to Obtain Ordered Weights and RD Evaluations for Residents With Weight Loss
Penalty
Summary
The facility failed to ensure two residents with significant weight loss were evaluated for nutrition status and received the services ordered to maintain acceptable nutritional parameters. The facility’s Weight Variance Committee policy stated that residents with weight variances were to be screened regularly by nursing and dietary staff, referred to the interdisciplinary committee, and reviewed until the issue was resolved. The policy also stated that residents with weight gain or loss greater than three pounds per week should be reviewed by the IDT for cause and further recommendations. For one resident, the record showed physician orders for an RD evaluation, referral to the RD for weight loss, weekly weights for four weeks, and enteral feeding. The resident had a documented seven-pound weight loss in one month, and the care plan addressed the weight loss with weekly weights and RD referral. The record showed the resident was discussed at the Weight Variance Committee meeting, but the medical record did not show the ordered weekly weight for the week of 6/8/26 was obtained, and there was no documented evidence that the resident was seen and evaluated by the RD as ordered. For the second resident, the record showed physician orders for weekly weights times four and referral to the RD for weight loss. The resident had weights showing a seven-pound loss from 5/21/26 to 5/26/26, a nine-pound loss by 6/2/26, and a ten-pound loss by 6/9/26. The medical record did not show a weight was obtained for the week of 6/16/26, and there was no documented evidence that the resident was seen and evaluated by the RD as ordered. Interviews with nursing leadership verified the missing weight documentation and the lack of RD assessment documentation for both residents.
Dialysis Access Care Not Followed
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end stage renal disease who was dependent on renal dialysis. The resident had a left arm AV shunt and a right upper chest perma-catheter, and the facility’s policy required that blood pressure not be taken on the extremity with the shunt and that the shunt be checked once each shift for bruit and thrill. The resident’s record did not show an order to monitor the left arm AV shunt or an order for no blood pressure and no venipuncture to the left arm. During review of the resident’s blood pressure documentation, multiple readings were recorded on the left arm over several days. On observation, the resident was seen with the right upper chest perma-catheter dressing, and the RN verified that the resident was high risk for bleeding and should have had emergency kit supplies kept at the bedside, but no supplies were present. Later interviews confirmed the resident had dialysis access sites on the left forearm and right upper chest, that blood pressure had been taken on the left arm, and that the nurse taking the blood pressure was not aware of the left arm AV shunt.
Medication Accountability and Order Clarification Deficiencies
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for two residents. For one resident, the Controlled Drug Record showed an Ativan 0.5 mg tablet was removed from the bubble pack on a day when the physician order scheduled the medication for Monday, Wednesday, and Friday. The facility’s Controlled Medications policy stated that if a controlled dose is removed but not given, it must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record, but the record did not show documentation of the waste by two licensed nurses. The DON stated the nurse reported popping out the tablet, realizing it was not ordered that day after reviewing the MAR, and then wasting the controlled substance without a second witness. For another resident, the physician order for famotidine 40 mg listed the indication as “supplement,” and the MAR showed the medication was administered daily for that same indication. The facility’s Prescriber Medication Orders policy stated that orders appearing inappropriate based on the resident’s age, condition, allergies, or diagnosis are to be verified with the attending physician, and that the prescriber is contacted to verify or clarify an order. The DON verified that the famotidine order listed “supplement” as the indication and stated the expectation was that each medication order had an appropriate indication for use.
Unlabeled Medications, Poor Temperature Monitoring, and Unattended Bedside Medication
Penalty
Summary
Medication labeling and storage practices were not followed for medications kept in Medication Carts A and B and in the Central Supply storage area. During inspection of Medication Cart A, an opened bottle of artificial tears for Resident 42 was found without resident-specific labeling. During inspection of Medication Cart B, an unlabeled Symbicort inhaler mouthpiece for Resident 65 and an unlabeled Incruse Ellipta inhaler mouthpiece for Resident 75 were found stored inside opened medication cartons. RN 3 verified the items were missing resident-specific information, and the IP stated that if unlabeled residents' medications were mixed up, it could lead to cross contamination with other residents. The Central Supply Room contained medications, including bisacodyl suppositories, acetaminophen suppositories, and docusate sodium liquid, but the room temperature log had last been documented in January 2026. The Central Supply Clerk stated that was the last time the room temperature had been recorded. The facility's policy stated medication storage conditions were to be monitored routinely, and the product labeling for the medications specified storage temperature ranges. Resident 109 was observed asleep in bed with a medication cup containing white cream on top of the bedside drawer without a label. LVN 5 identified the cream as zinc oxide for Resident 109's skin problem and initially disposed of the cup in a regular trash can before retrieving it and taking it to the medication room. Resident 109's record showed a physician order for zinc oxide to treat a sacral redness pressure injury, and the resident had no capacity to understand and make decisions. The record also did not show an order for self-administration of medication, and RN 3 verified the resident was unable to self-administer medications.
Menu Not Followed for Two Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure the menu was followed for two residents on therapeutic pureed diets, Residents 29 and 95, during the lunch meal. The facility’s menu for Monday 6/15/26 listed cappuccino mousse as part of the lunch meal, and the facility’s Summer Menus document for pureed IDDSI Level 4 also included cappuccino mousse for that meal. During the lunch observation, Resident 29 was served pureed beef, pureed bread, pureed sweet potato fries, pureed corn, milk, water, juice, and a vanilla health shake, but was not observed receiving cappuccino mousse. Resident 95 was served pureed beef, pureed bread, pureed sweet potato fries, pureed corn, milk, water, a vanilla health shake, and yogurt, but was also not observed receiving cappuccino mousse. Resident 29 had no capacity to understand and make decisions and had a physician’s order for a large portion, fortified, no added salt pureed texture diet with regular/thin liquids. Resident 95 also had no capacity to understand and make decisions and had a physician’s order for a fortified, no added salt pureed texture diet with regular/thin liquids. During a concurrent interview and observation, the IP verified that residents on a pureed diet should receive the cappuccino mousse dessert for the lunch meal. The DON was informed and acknowledged the findings.
Inaccurate Resident Admission Documentation in Medical Record
Penalty
Summary
The facility failed to ensure the medical record for one sampled resident, Resident 47, was accurate. Review of the resident’s H&P showed documentation that the resident was admitted to Facility A, a different facility name and not the actual facility. Review of the resident’s Physician Progress Notes also showed repeated documentation that Resident 47 was admitted at Facility A on multiple dates, rather than at the actual facility. The facility’s P&P titled Physician Services, revised 1/2018, stated that a physician, MD, or DO must personally approve in writing a recommendation that an individual be admitted to the facility. During interview and concurrent medical record review, the MRD verified the inaccurate documentation. The DON also verified the findings and stated the MD was aware of the inaccurate documentation on the admitting facility in the H&P and Physician Progress Note.
Inaccurate MDS Coding for Left Hand Splint Assistance
Penalty
Summary
The facility failed to complete an accurate MDS assessment for Resident 11 by not coding the application of a left hand splint. Resident 11 was admitted and later readmitted to the facility, and the H&P dated 5/31/26 showed the resident was unable to make independent medical decisions. The physician's orders included applying a hand splint to the left hand five times a week or as tolerated every Monday, Tuesday, Thursday, Friday, and Saturday. However, the MDS assessment under Section O0500, Restorative Nursing Programs, coded the resident for none or less than 15 minutes a day for splint assistance. Restorative Nursing documentation for April 2026 showed the left hand splint was applied on 4/3, 4/4, 4/6, 4/7, 4/9, and 4/10/26 for four hours. During an interview and concurrent record review, the DON reviewed the record and verified the findings.
Resident Eloped Through Secured Front Door
Penalty
Summary
The facility failed to ensure a safe and secure environment for one resident when the resident left the secured facility without staff knowledge and was later found in an emergency department approximately 50 miles away. The resident was last seen by staff at about 2015 hours and was noted missing around 2150 hours. Facility review of surveillance footage showed the resident, who used a wheelchair, entered the front lobby area, punched in a code at the keypad on the secured front door, opened the door, and propelled herself out of the building and down the sidewalk away from the facility. The resident had diagnoses including schizoaffective disorder, chronic low back pain, depression, and diabetes mellitus, and the H&P stated she had no capacity to understand and make medical decisions. Her medication orders included antipsychotic medications, a psychotropic medication, insulin, metformin, baclofen, and a lidocaine patch. The resident’s elopement risk assessment scored 18, which was high risk, but the form was marked as not an elopement risk. The care plan did not address elopement risk, and the DON later stated the rationale for not identifying the resident as an elopement risk was not appropriate. Staff interviews showed the resident frequently wheeled around the facility, spent time near the front lobby, attended smoke breaks, and had been agitated and responding to internal stimuli before the event. The resident was later evaluated in the ED with bilateral lower extremity edema, disorganized responses, unusual behavior, and poor hygiene. Psychiatric consultation documented acute psychosis, disorganized thought process, visual and auditory hallucinations, and the resident was placed on a 5150 hold for being gravely disabled.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, as required by its abuse prevention and reporting policy. The facility’s policy, revised in 4/2024, defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm or mental anguish and emphasized protection of resident rights and investigation/reporting of alleged violations. Despite this policy, an incident occurred in which one cognitively impaired resident (Resident 2) pushed another cognitively impaired resident (Resident 1) when Resident 1 attempted to enter Resident 2’s room. On the date of the incident, the facility’s SOC 341 documented that Resident 1 tried to get into Resident 2’s room, and Resident 2 pushed Resident 1 in the chest, causing Resident 1 to back off, lose balance, and fall. Resident 2’s medical record and MDS showed severe cognitive impairment, and progress notes documented that Resident 2 stated she was trying to stop Resident 1 from entering her room and admitted to pushing her. A nurse (LVN 3) found Resident 1 on the floor near a room, crying and complaining of hip pain, with Resident 2 standing by the door and stating she had given Resident 1 “a little shove” to stop her from going into the room. Another nurse (LVN 1) confirmed that Resident 2 admitted to pushing Resident 1. Resident 1’s medical record showed that she lacked capacity to understand and make decisions and, prior to the incident, required only set-up or clean-up assistance for bed mobility and transfers and could walk 150 feet with supervision or touching assistance without an assistive device. Following the fall, Resident 1 complained of left hip pain, and radiology on the date of the incident showed fractures of the left superior and inferior pubic rami, with a subsequent CT scan at the acute care hospital confirming recent fractures of the left lateral superior pubic ramus and left inferior pubic ramus. After the incident, therapy documentation reflected a decline in functional status, with Resident 1 requiring partial to maximal assistance for bed mobility, transfers, and ambulation with a two-wheeled walker, and nursing and CNA interviews described increased pain, frequent screaming and yelling due to pain, and dependence on staff for activities of daily living. These findings support that the facility failed to protect Resident 1 from physical abuse by another resident in accordance with its abuse prevention policy.
Failure to Timely Report Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Reporting and Prevention policy and the requirements of section 1150B of the Act and state law for timely reporting of a reasonable suspicion of a crime. Facility policy required that alleged abuse resulting in serious bodily injury, including physical abuse and resident-to-resident altercations with actual harm, be reported to CDPH, the ombudsman, and local law enforcement immediately, but no later than two hours after forming the suspicion. On the date of the incident, two residents were involved in an altercation at approximately 1620–1700 hours when one resident, who had severe cognitive impairment per MDS, pushed another resident who was attempting to enter her room. Multiple staff interviews confirmed that the pushing incident was reported to nursing staff on the same day, and that the pushing resident admitted to giving the other resident a “little shove” to stop her from entering the room. The pushed resident, who lacked capacity to understand and make decisions per H&P, was found on the floor near the room, crying and complaining of left hip pain rated five out of ten. Progress notes documented the event as an unwitnessed fall, and subsequent radiology showed fractures of the left superior and inferior pubic rami, with the age of the fracture indeterminate. Despite the facility’s policy that any allegation of physical abuse and resident-to-resident altercations with actual harm be reported within two hours, the RN did not notify CDPH, the ombudsman, or local law enforcement within that timeframe. Instead, the SOC 341 report identifying one resident as the alleged victim and the other as the alleged abuser was submitted the following day at 0906 hours, outside the required two-hour reporting window. The DON later acknowledged that the incident should have been reported within two hours and that incorrect information about injury status had been relayed to him.
Failure to Notify MD of Abnormal X‑ray and Inadequate Pain Management After Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide required skilled nursing services to a cognitively impaired resident who lacked capacity to understand and make decisions. The resident was admitted in June and had an H&P documenting lack of decision-making capacity. On a later date, the physician ordered bilateral hip and pelvis x‑rays. The radiology report showed fractures of the left superior and inferior pubic rami with indeterminate age. Facility policy on Laboratory and Radiology Documentation required licensed nurses to promptly call the physician with abnormal radiology results. Nursing documentation showed the x‑ray result was faxed to the primary physician, but there was no evidence the physician was called about the abnormal finding. RN 1 confirmed the record lacked documentation of a call, and RN 2 stated he only faxed the report and did not notify the physician because the fracture age was indeterminate. The DON stated the expectation was immediate reporting of abnormal radiology results to prevent delay in treatment. The facility also failed to follow its Pain Management Protocol after the resident experienced an unwitnessed fall. On the date of the fall, documentation on the SBAR Communication Form and Progress Notes showed the resident was found on the floor, crying, pointing to the left hip, and reporting pain at 5/10. The subsequent radiology report confirmed fractures of the left superior and inferior pubic rami. Existing physician orders included PRN acetaminophen 325 mg, two tablets every six hours as needed for mild pain (1–3), and a later order for a Lidoderm 5% patch to the left hip for seven days. LVN 3, who found the resident on the floor, stated the resident was crying and complaining of hip pain but did not recall whether acetaminophen was administered after the fall. RN 1 also stated he did not know if LVN 3 gave acetaminophen at that time. Medication administration records for January showed acetaminophen was repeatedly given for pain scores that exceeded the ordered “mild pain” range, including pain levels of 4–8, and the Lidoderm patch was applied daily for seven days. Nursing progress notes and the medical record did not show that the physician was notified when the resident’s pain exceeded the mild range on multiple documented occasions. The record also lacked a pain documentation flow sheet required by the facility’s Pain Management Protocol to record each PRN dose, the resident’s response, and any non‑pharmacological interventions. RN 1 verified that pain scores of 4 and above were not reported to the physician until a later physician visit and confirmed the absence of required pain flow sheet documentation and monitoring details in the MAR.
Sanitary Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to sanitary requirements in the kitchen, as evidenced by several observations during an inspection. The facility did not use the correct cutting board for raw poultry, which could lead to cross-contamination. Specifically, a dietary aide was observed using a red cutting board for raw chicken instead of the designated yellow one. Additionally, the sanitizing solution used for cleaning food preparation surfaces was found to be below the required concentration, with a test showing it at 150 ppm instead of the necessary 200 ppm. This was confirmed by the dietary aide and the Certified Dietary Manager (CDM), who stated that the solution should be changed every four hours or as needed. Further observations revealed that kitchen equipment and utensils were not properly cleaned or air-dried. A blender, microwave, toaster, and robocoupe were found with residues and build-up, indicating they were not clean to sight and touch. Moreover, items such as steam table pans and a blender were stored wet, which is against the requirement for air-drying to prevent microorganism growth. Maintenance tools like brooms were also improperly stored on the floor, posing a risk of contamination. These deficiencies were verified by the dietary aide and confirmed in interviews with the facility's administration and dietary management.
Failure to Assess and Plan for Resident's Self-Administration of Supplements
Penalty
Summary
The facility failed to assess and develop a plan of care for a resident who was self-administering supplements, specifically Flax Seed Oil and Omegas + Tumeric, without a physician's order or an assessment by the interdisciplinary team (IDT). The resident, who was cognitively intact with a BIMS score of 15, had been self-administering these supplements since admission. However, there was no documentation in the medical records, including the Order Summary Report and Plan of Care, to indicate that the resident had been assessed for the safety of self-administration or that a care plan had been developed. During observations and interviews, it was confirmed that the resident had the supplements at the bedside and had been taking them twice daily. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) verified the absence of a physician's order and the lack of an assessment or care plan addressing the self-administration of these medications. The facility's policy required that residents be assessed by the IDT and approved by a physician for self-administration, which was not followed in this case.
Failure to Conduct Level II Mental Health Evaluation
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 106, received a Level II mental health evaluation after a positive Level I PASRR screening for serious mental illness. Resident 106 was discharged from an acute care hospital and admitted to the facility without the necessary follow-up for a Level II evaluation. The initial Level I screening, completed at the acute care hospital, indicated the need for a Level II evaluation, but this was not scheduled because the resident was discharged from the hospital, and the case was closed. Upon review, it was found that the facility did not notify the California Department of Health Care Services Level II evaluators of Resident 106's admission. RN 1 confirmed there was no documentation indicating that the evaluators were aware of the resident's current status. The facility should have conducted another PASRR Level I screening upon the resident's admission to ensure the necessary Level II evaluation was completed, which could have determined the need for specialized services for the resident.
Inadequate PASRR Screening and Follow-Up
Penalty
Summary
The facility failed to ensure that PASRR screenings for two residents were completed by the appropriate staff member. The Business Office Manager, who was not qualified according to the facility's policy, completed the PASRR Level 1 screenings for both residents. This was contrary to the requirement that a qualified staff member with knowledge of medical terminology and the residents' medical and behavioral history should complete the screenings. Additionally, the facility did not verify with the Department of Health Care Services (DHCS) when one resident's PASRR Level 1 screening was closed due to the facility staff's lack of response to multiple communication attempts by DHCS. The medical records for one resident showed that the PASRR Level 1 screening resulted in a Categorical Review, but the facility staff did not follow up with DHCS or submit a new Level 1 screening after the case was closed. An interview with a registered nurse confirmed that the Business Office Manager's computer was used to access the PASRR website, and there was no documented evidence of follow-up actions for the closed case. This lack of proper screening and follow-up posed a risk for the residents not receiving adequate services and assessments related to their mental disorders.
Failure to Provide Dermatology Consult as Ordered
Penalty
Summary
The facility failed to provide a dermatology consult for a resident as ordered by the physician. The resident, who was unable to make decisions, had a wound on the left forearm that required a dermatology consult scheduled for a specific date. However, due to an error in arranging the appropriate transportation, the resident missed the appointment. The facility did not reschedule the dermatology consult, and there was no documented follow-up to ensure the resident received the necessary care. Interviews with facility staff revealed that the licensed nurses were responsible for scheduling physician appointments and coordinating transportation if needed. Despite this protocol, the dermatology consult was not rescheduled after the missed appointment, and there was no documentation of any follow-up actions. The Director of Nursing acknowledged the findings, confirming the deficiency in providing the necessary services as ordered by the physician.
Failure to Apply Splints as Ordered for Resident
Penalty
Summary
The facility failed to provide necessary restorative nursing services for a resident, identified as Resident 53, who was reviewed for positioning and mobility. The deficiency was observed when Resident 53 was not applied with carrot splints to both hands and AFOs to both feet for the required duration of four hours as per the physician's order. During an initial tour, Resident 53 was observed in bed with contracted hands and no splints on the hands, although splints were present on the feet. Subsequent observations showed rolled towels on the resident's hands instead of the prescribed splints. The medical record review revealed that Resident 53 had severe cognitive impairment and was dependent on staff assistance for self-care and mobility, with impairments in both upper and lower extremities. The physician's orders specified the application of splints for five days a week for four hours as tolerated. However, the Restorative Nursing form documented only two minutes of splint application daily, lacking evidence of the required duration. Interviews with the RNA and DON confirmed the findings, indicating a failure to document the hours the splints were applied, which was necessary to assess the resident's tolerance to the splints.
Failure to Document and Address Elopement Risk for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 28, was free from accident hazards related to elopement risks. Despite observations and staff reports indicating that Resident 28 exhibited wandering and exit-seeking behaviors, such as verbalizing a desire to leave the facility and standing by the locked front door, the facility did not accurately assess the resident's risk for elopement. The resident was not documented as a high risk for elopement, and there was a lack of documentation regarding the resident's wandering behaviors and the interventions used. Additionally, the facility did not provide Resident 28 with an ID bracelet as per the elopement assessment plan, and there was no documentation of the resident refusing or removing the ID bracelet. Interviews with facility staff, including CNAs and the DSD, confirmed that Resident 28 had a history of expressing a desire to leave the facility and had been observed packing belongings and waiting by the door for someone to pick her up. However, there was no care plan developed to address the resident's non-compliance with wearing an ID bracelet, nor was there documentation of the resident's behaviors in the medical record. The lack of proper documentation and failure to implement the elopement protocol for Resident 28 posed a risk of delayed identification and response in the event of an elopement incident.
Failure to Update GT Feeding Rate and Care Plan
Penalty
Summary
The facility failed to ensure that the gastrostomy tube (GT) feeding rate for Resident 62 was updated according to the physician's orders and did not revise the resident's care plans to reflect the new orders. Resident 62 was observed with a GT feeding formula running at 60 ml/hr, despite a physician's order dated 9/14/24 to increase the rate to 65 ml/hr. This discrepancy was confirmed during an observation and interview with LVN 6, who acknowledged the incorrect rate and the presence of conflicting GT feeding orders. Additionally, the facility's Plan of Care for Resident 62, initiated on 4/7/24, did not reflect the updated GT feeding rate as per the physician's order on 9/14/24. The care plan continued to list the previous rate of 60 ml/hr, which was based on an earlier recommendation from the registered dietitian on 8/27/24. These failures posed a risk of not providing the necessary GT care and interventions to Resident 62, as the care plans were not aligned with the current medical orders.
Failure to Monitor Post-Dialysis Vital Signs and Weight
Penalty
Summary
The facility failed to provide necessary post-dialysis care for a resident requiring dialysis services. Specifically, the facility did not monitor the resident's vital signs and weight after returning from dialysis sessions on multiple occasions, including 12/21, 1/2, 1/4, 1/9, 1/14, 1/16, and 1/18. This lack of monitoring was confirmed through a review of the resident's medical records, which showed no documentation of vital signs or post-dialysis weight checks on these dates. Additionally, the facility's policies and procedures for dialysis care, which require the completion of a post-dialysis checklist including vital signs, were not followed. An interview with RN 1 confirmed the absence of documentation for the resident's vital signs and post-dialysis weight checks on the specified dates. The RN also verified that the resident's post-dialysis weight on 1/18 was not followed up with the dialysis facility. This oversight in monitoring vital signs and weight post-dialysis had the potential to delay care for any complications arising from the dialysis treatment.
Failure to Obtain Consent and Assess Alternatives for Side Rail Use
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 13, remained free from accident hazards due to the use of side rails. The facility did not obtain a physician's order or informed consent for the use of side rails, nor did they review the risks and benefits with the resident or their representative. Additionally, the facility did not attempt the least restrictive alternatives before resorting to side rails, and there was no care plan developed to address the use of side rails for Resident 13. This oversight was observed during a facility tour and through interviews with the resident and staff, as well as a review of the resident's medical records. Resident 13, who had a significant diagnosis of morbid obesity and required partial to moderate assistance for bed mobility, was observed using side rails for turning and getting out of bed. Despite the resident's capacity to understand and make decisions, there was no documented evidence of a comprehensive care assessment or any attempts to use alternatives such as two-person assistance, pillows, or an overhead trapeze. Interviews with facility staff, including a CNA and an LVN, confirmed the lack of necessary documentation and procedures for the use of side rails, which was acknowledged by the Director of Nursing.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to two residents, leading to medication administration errors and documentation issues. For one resident, the facility did not administer docusate sodium as ordered by the physician, and the medication administration record (MAR) was inaccurately documented. The Licensed Vocational Nurse (LVN) responsible for administering the medication stated that she did not give the dose after clarifying the order with the physician. Additionally, the LVN admitted to documenting the administration of medications on the MAR before actually administering them, contrary to the facility's policy. For another resident, the facility failed to accurately document the administration of a controlled medication, tramadol, which was signed out but not recorded in the MAR. The LVN acknowledged that she administered the medication but forgot to document it. This oversight in documentation could lead to potential medication errors and issues with tracking controlled substances. Furthermore, the facility did not properly conduct narcotic inventory checks as required by their policy. The Narcotic Check Sheet for Medication Cart B had multiple missing nurses' signatures during shift changes, indicating that the physical inventory of controlled medications was not consistently verified by two licensed nurses. This lapse in procedure could increase the risk of medication diversion and errors in medication management.
Failure to Adhere to Medication Parameters for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs, leading to potential adverse effects. Resident 37 was administered metoprolol and clonidine despite having blood pressure readings below the parameters prescribed by the physician. Specifically, metoprolol was given on three occasions with systolic blood pressure (SBP) readings of 109, 104, and 101 mmHg, and clonidine was administered once with an SBP of 99 mmHg, all below the prescribed threshold of 110 mmHg. These actions were verified by RN 1 during an interview and medical record review. Similarly, Resident 53 was administered metoprolol on four occasions with SBP readings of 116, 116, 115, and 114 mmHg, which were below the physician's prescribed parameter of 120 mmHg. This was confirmed by RN 3 during an interview and medical record review. The failure to adhere to the prescribed parameters for medication administration had the potential to cause significant side effects such as hypotension, thereby negatively affecting the residents' health and well-being.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that seven residents were free from unnecessary psychotropic drugs, as evidenced by several deficiencies in monitoring, informed consent, and documentation. For one resident, the facility did not accurately monitor meal intake related to the use of Remeron, an antidepressant medication. The documentation of meal intake was inconsistent and did not match the CNA's Documentation Survey Report, leading to discrepancies in the monthly behavior summary. Another resident's informed consent for multiple medications, including Depakene, Remeron, and risperidone, was not renewed after six months, and the facility failed to monitor blood pressure for orthostatic hypotension as ordered by the physician. The facility also failed to monitor another resident for side effects related to the use of lorazepam, an antianxiety medication. Additionally, informed consent was not obtained prior to the administration of risperidone for another resident, and the facility did not have documentation of informed consent from the resident or their responsible party. Furthermore, informed consents for several medications, including trazodone, Zyprexa, and bupropion, were not renewed after six months for another resident, despite the facility's policy requiring such renewals. In another case, informed consents for Seroquel and Depakote were not renewed after six months for a resident, and the facility failed to renew informed consents for Depakote ER, fluvoxamine maleate, olanzapine, and risperidone for another resident. These failures had the potential to result in adverse complications from the medications and hindered the ability to provide accurate data to prescribers for dose adjustments. Additionally, these deficiencies could lead to residents and their responsible parties not being informed about their medications and potential side effects.
Failure to Administer Zyprexa as Ordered
Penalty
Summary
The facility failed to ensure that Resident 20 was free from significant medication errors, specifically regarding the administration of Zyprexa, an antipsychotic medication. The physician had ordered Zyprexa 10 mg to be administered at bedtime for the resident's schizoaffective disorder, but the medication was not administered from January 17 to January 19, 2025, as the Medication Administration Record (MAR) was left blank for these dates. The medication was only documented as administered on January 20 and 21, 2025, despite the medication not being available until January 22, 2025. This discrepancy was confirmed through interviews with LVN 1 and LVN 2, who acknowledged the medication was not on hand and that the MAR was inaccurately signed. The facility's policies and procedures for medication administration and physician orders were not followed, as the order for Zyprexa was not transmitted to the pharmacy in a timely manner, resulting in a delay in receiving the medication. The pharmacy confirmed that the order was received on January 20, 2025, but the medication was not delivered until January 22, 2025. The Director of Nursing (DON) acknowledged that the charge nurses should have followed up with the pharmacy and that it was unacceptable to document medication administration when the medication was not available. The failure to administer the medication as ordered placed Resident 20 at risk for medical complications.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in two instances involving Medication Carts A and B. In the first instance, during an inspection of Medication Cart A, it was observed that orally administered medications were stored together with externally used medications and supplies. Specifically, a box of loperamide HCL tablets, a bottle of sodium chloride tablets, Salonpas patches, and a tube of Refresh Celluvisc were found in the same compartment. LVN 1 confirmed these findings and acknowledged that these medications should not be stored together due to their different routes of administration. In the second instance, Medication Cart B was found unlocked and unattended in the hallway, with facility staff and residents passing by. This was verified by the DON and LVN 1, who admitted that the cart was left unlocked after LVN 1 had taken narcotic medications from it and forgot to lock it. These lapses in medication storage practices had the potential to negatively impact residents' well-being and increase the risk of drug diversion or misuse.
Deficiencies in Kitchen Staff Competency and Food Safety Practices
Penalty
Summary
The facility failed to ensure that kitchen staff were competent in their duties, specifically in testing sanitizing solutions and using the correct cutting boards. Two dietary aides were unable to correctly test the sanitizing solution used for food preparation surfaces and equipment. One dietary aide held the test strip in the solution for an incorrect duration, resulting in an inaccurate reading of 150 ppm, which was confirmed to be incorrect. The Certified Dietary Manager (CDM) admitted that no in-service training on testing the sanitizing solution had been provided to the kitchen staff. Additionally, another dietary aide was unable to demonstrate or describe the manual dishwashing procedure, including testing the concentration of the sanitizing solution. Although the CDM provided in-service training and written instructions, there was no return demonstration required to evaluate the employee's competency. This lack of competency evaluation posed a risk of improper sanitization of dishes, potentially leading to foodborne illnesses among the 94 residents receiving food from the kitchen. Furthermore, a cook was observed using the wrong cutting board for raw poultry, using a red board instead of the designated yellow board. The CDM confirmed that no in-service training on the proper use of cutting boards had been conducted in 2024. These deficiencies in staff training and competency evaluation in food safety practices posed a risk of exposure to unsafe food handling practices for the residents.
Nutritional Deficiency in Vegetarian Diets
Penalty
Summary
The facility failed to meet the nutritional needs of two residents who were on vegetarian diets. During a lunch meal service, these residents received a grilled cheese sandwich that provided only nine grams of protein, compared to the 28 grams of protein provided by the regular menu's meatloaf entree. This discrepancy was observed during a review of the facility's meal service and dietary documentation. The facility's documentation did not include a specific vegetarian menu or portion sizes, which contributed to the inadequate protein provision for these residents. Resident 11, who had a medical history of vitamin D deficiency and hypocalcemia, was observed receiving a lunch tray with a grilled cheese sandwich, peas, and juices. Resident 70, diagnosed with severe protein-calorie malnutrition and pulmonary disease, received a similar meal. Interviews with facility staff revealed that there was no established vegetarian menu or portion guidelines, and the Registered Dietitian confirmed that vegetarian meals should be nutritionally equivalent to regular menu entrees. The lack of a structured vegetarian menu and portion sizes led to the nutritional deficiency observed in these residents' meals.
Deficiency in Safe Food Handling Practices for Visitor-Brought Food
Penalty
Summary
The facility failed to ensure proper storage, preparation, and safe food handling practices for food brought in by family members or visitors, which could potentially lead to foodborne illness among the 94 residents receiving an oral diet. The facility's policy, revised in July 2019, discourages visitors from bringing potentially hazardous foods and mandates that such foods be consumed immediately or discarded, without reheating or storage. However, interviews with staff revealed inconsistencies in the implementation of this policy. RN 1 stated that food could be stored for 24 hours, and RN 4 confirmed that food could be reheated in a microwave at Nursing Station 1, which was observed to be unclean. Additionally, there was no evidence of recent training on safe food handling for staff, and no information was provided to visitors regarding safe food handling practices. The Director of Nursing (DON) and Infection Preventionist (IP) were unaware of any written information provided to visitors about safe food handling, and the IP confirmed that no education on safe food handling had been provided to staff. The facility's failure to adhere to its own policy and lack of staff training and visitor education on safe food handling practices contributed to the deficiency. This oversight had the potential to compromise the health and safety of residents by increasing the risk of foodborne illnesses.
Failure to Provide Required Hospice Services
Penalty
Summary
The facility failed to provide necessary hospice care services for a resident, identified as Resident 49, who was under hospice care for senile degeneration of the brain. The facility did not ensure that the resident received the required hospice care visits, which included three weekly visits by a Certified Home Health Aide (CHHA) and one to three weekly visits by a Skilled Nurse (SN). Over several weeks, there were multiple instances where the CHHA visits were fewer than ordered, and there was no documented evidence of SN visits. This lack of adherence to the prescribed hospice care schedule was confirmed through a review of the resident's medical records and hospice visit logs. Additionally, the facility did not assign a designated hospice coordinator to oversee and coordinate the hospice services for Resident 49. This absence of a hospice coordinator led to delays in communication between the hospice provider and the facility, potentially affecting the resident's care. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the visitation logs had not been reviewed, and the facility acknowledged the need for a hospice coordinator to ensure the hospice care plan was followed as intended.
Infection Control Lapses in Laundry and Medication Cart Areas
Penalty
Summary
The facility failed to implement appropriate infection control practices in two key areas, as observed during a survey. In the laundry room's clean folding area, personal belongings of employees and residents were found, including a large pink purse, a cellphone charger, lotion, eye goggles, bottled water, a remote control, and reading glasses. The Environmental Services Director (ESD) confirmed these findings and acknowledged that the items should not be present in the clean area as they could contaminate clean clothes and linens. The ESD was unable to confirm if the items from the soiled linens, such as the reading glasses and remote control, were sanitized. The Infection Preventionist (IP) also confirmed that the clean folding area should be free of personal belongings to prevent contamination. Additionally, the facility failed to maintain cleanliness and integrity of the spoon containers on Medication Carts B and C. The spoon container on Medication Cart B had broken plastic pieces, while the container on Medication Cart C was cracked and taped. Both containers were observed to have dirt and a brown dry substance on them. The IP verified these observations and stated that the spoon containers should be clean to prevent the spread of infection, as they are used for medication administration.
Deficiencies in Equipment Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain essential equipment in proper working order, as evidenced by several deficiencies. The ice machine was not cleaned and sanitized according to the manufacturer's guidelines. The Maintenance Director admitted to using incorrect proportions of descaler and water for cleaning and sanitizing, which did not align with the manufacturer's instructions. This discrepancy was confirmed during an interview with the Maintenance Director, who stated that the ice machine was cleaned monthly by the facility's staff and annually by an external company. Additionally, the microwave at Station 1 was found to be in an unsafe condition, with a charred and burnt interior. This was confirmed by RN 1, who stated that the microwave was used to heat food brought in for residents. The Maintenance Director was notified and removed the microwave. Furthermore, ice buildup was observed in two medication refrigerators and one specimen refrigerator, which was verified by the DON and the Infection Preventionist during inspections. These issues indicate a failure to maintain equipment in a safe and sanitary condition, potentially affecting the well-being of residents.
Deficiency in Bed Entrapment Assessments and Inspections
Penalty
Summary
The facility failed to ensure that entrapment assessments were completed and measurements were recorded during bed inspections for residents using side rails. This deficiency was observed in four residents who were reviewed for side rail use. The facility also did not conduct regular inspections of all beds, which could potentially lead to resident entrapment, serious injury, or death. The facility's policies and procedures required regular inspections and assessments to prevent such risks, but these were not adequately followed. For Resident 13, there was no documented evidence of an entrapment assessment prior to the installation of side rails, despite the resident's use of the rails for mobility assistance. The maintenance department was responsible for installing the side rails and measuring gaps, but the necessary assessments were not completed. Similarly, Resident 29's records showed that while the resident requested grab bars and understood the risks, the entrapment assessment was incomplete, with certain zones not evaluated. The maintenance staff was responsible for these evaluations, but the documentation was inconsistent and incomplete. Resident 37's records indicated that while the resident was cognitively intact and used grab bars for mobility, the entrapment assessment was not fully conducted, with some zones marked as not applicable without proper justification. Additionally, Resident 5's records showed that the entrapment assessment did not include Zone 2, which was necessary for a complete evaluation. The Environmental Services Director confirmed these findings, acknowledging that the assessments were not conducted with the resident in bed and that documentation was lacking for beds without grab bars.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, identified as Resident 72 and Resident 4, due to the presence of scratches and unpainted areas on the walls adjacent to their beds. During an observation and interview, Resident 72, who was lying in her bed in Room A, expressed that having the wall repaired and painted would be nice. Similarly, Resident 4, who was observed lying in her bed watching television in Room B, stated that she spent most of her time in her room and would like the wall to be repaired. These conditions were noted during observations conducted on January 22, 2025, and the findings were communicated to the Administrator on January 27, 2025.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide a notice of transfer or discharge to the Ombudsman for a resident, identified as Resident 109, who was reviewed for closed records. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy, revised in January 2017, mandates that a copy of the notice of transfer or discharge be sent to a representative of the Office of the State Long-Term Care Ombudsman and that the reasons for the transfer or discharge be recorded in the resident's medical record. However, during the review, it was found that the Ombudsman did not receive the notification of discharge for Resident 109, which was confirmed by the Ombudsman herself. Resident 109 was admitted to the facility for short-term respite care but was discharged after one day due to aggressive and combative behaviors. The Social Services Director (SSD) confirmed that the notification of discharge was supposed to be provided to the responsible party, the Ombudsman, and the VA hospital in this case. Despite attempts by RN 2 to fax the notice of discharge to the Ombudsman on the day of the resident's discharge, the notice was not found in Resident 109's medical record, and the Ombudsman did not receive it. This oversight posed a risk of Resident 109 and their representative not being aware of their appeal rights, potentially jeopardizing the appeal process if they felt the discharge was inappropriate or involuntary.
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Illustrative
What surveyors actually found near you
We read the 6,108 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Palma Nursing Center | 0 mi | ★★★★★ | 1 | 0 |
| Sun Mar Nursing Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Harbor Villa Care Center | 1.8 mi | ★★★★★ | 24 | 0 |
| St. Catherine Healthcare | 1.8 mi | ★★★★★ | 19 | 0 |
| Parkview Healthcare Center | 1.8 mi | ★★★★★ | 19 | 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 October 2026) and official state health department websites.