Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lemon Grove Care And Rehabilitation Center during CMS and state inspections, most recent first.
QAA failed to identify, monitor, and address medication administration, medication storage, and equipment maintenance issues found during recertification. The ADM and DON stated they had reviewed prior survey findings, but medication storage was dropped from QAPI after staff education and auditing, and the current medication error rate and storage issues showed improvement had not been achieved before survey. The ADM also stated the Director of Maintenance did not attend quarterly QAA meetings, and equipment safety issues should have been brought forward before survey. The facility's QAPI plan did not include implementation or monitoring for these problem areas.
Infection control monitoring was incomplete, with no documented vaccine refusal follow-up, no hand hygiene surveillance for several months, and no documented antibiotic surveillance analysis or communication with the MD and pharmacist. In addition, one resident’s oxygen tubing was undated, and another resident’s oxygen tubing and nebulizer mask were not dated or stored in a plastic bag as required by facility practice and staff statements.
Failure to Assist Dependent Residents With ADLs: A resident with MS and total transfer dependence was left in bed and not assisted out of bed, two cognitively impaired residents were not cued for hand hygiene before meals, and three residents had long fingernails without routine nail care. Staff interviews confirmed the residents needed assistance, cueing, or nail care for hygiene and ADL support.
A resident with anticoagulant use and a history of hematoma had coffee ground emesis and later a change in LOC, but staff did not document an immediate assessment or promptly notify the MD/NP; CPR was later initiated and the resident was transferred to the hospital, where the resident expired. In a separate event, staff performed multiple BG checks on another resident receiving insulin without a physician order and at close intervals, and the DON confirmed the checks should not have been done without an order.
Failure to Monitor Resident on Anticoagulant Therapy: A resident receiving rivaroxaban for stroke prevention was not monitored for signs of bruising or bleeding for several months. The record showed no documented monitoring during that period, and an LPN stated the resident should have been monitored because the resident could not express symptoms. The DON stated LNs were expected to monitor residents on anticoagulants for bleeding and bruising.
Medication Administration Errors Exceeded Allowed Rate: A nurse administered multiple medications by mouth to a resident with dysphagia and G-tube status even though the orders required administration via G-tube or enterally. The MAR and order summary showed the routes did not match, and interviews confirmed staff expected the MAR and five rights to be checked before giving medications. The facility’s observed medication error rate was 19.51%, with 8 errors out of 41 opportunities.
Incomplete Antibiotic Stewardship Monitoring: The facility failed to follow its Antibiotic Stewardship policy when the IP did not comprehensively track and monitor antibiotic use. Surveyors found that the antibiotic surveillance did not match the case map, and there was no documented evidence of data analysis, length of therapy, days of therapy, or the reason antibiotics were used. The DSD/IP, DON in training, and DON could not discuss the Infection Control Program, and there was no evidence of communication with the Medical Director and pharmacist about opportunities for improvement.
Unsafe Resident Equipment and Peeling Handrails: Handrails in the secured unit had peeling paint, and staff observed a bed remote cord with exposed wires for a resident with paranoid schizophrenia. The DM and an LPN noted the paint kept peeling, and a CNA stated the frayed cord was a safety issue that could poke the resident. The issue was not documented in the maintenance book, and the DM could not identify when the room was last inspected.
A resident’s urinary drainage bag was left uncovered and visible, and another resident was fed while a CNA stood over her head instead of maintaining eye level. Staff and the DON stated both situations were dignity issues and that residents should be treated with privacy, dignity, and respect.
An LPN failed to promptly notify the physician/NP when a resident on anticoagulant therapy had large coffee ground emesis and later a change in LOC. Progress notes showed the vomiting occurred overnight, but the NP was not notified until more than 8 hours later. The resident was then transferred to the hospital after CPR was initiated and later expired.
Incomplete investigation of abuse allegation: A resident reported that a male RNA inappropriately touched her breast, with two unwitnessed incidents described and one roommate hearing part of the exchange but not witnessing the event. The resident had severe cognitive impairment and lacked decision-making capacity per H&P and BIMS. The DON stated the investigation did not document interview dates and times for the resident, roommate, or RNA, and no other residents or staff with contact with the accused employee were interviewed, despite facility policy requiring broader interviews and review of the circumstances.
A resident with ESRD who lacked decision-making capacity was transferred to an acute care hospital for a change in condition, but the facility did not document that his RP received written notice of the transfer or the bed hold policy. The bed hold form was incomplete, with key transfer and notification sections left blank, and the DON stated written notice should have been provided because it was the resident's right.
The facility failed to accurately assess and code RNA services and resident status on the MDS for two residents. One resident with stroke-related left-sided weakness had physician-ordered passive ROM and restorative notes, but the MDS showed no restorative nursing services because the MDSN did not review the nursing progress notes where the RNA documented care. Another resident with left hemiplegia had inconsistent admission and readmission assessments, and staff including the LN, MDSN, and DON stated the record and MDS were not accurate.
A resident admitted with schizophrenia had a PASRR I that was positive and triggered a PASRR II, but there was no documented evidence the PASRR II was completed. The MDSN stated she arranged PASRR II interviews with State evaluators, but later realized the evaluation had never been completed; the PASRR II document instead noted the case was closed after staff were unresponsive to scheduling attempts. The DON stated PASRR II's were important for proper care and recommended services.
A resident with MS and significant transfer dependence was not provided individualized activities aligned with his care plan and preferences. He stated he stayed in bed, wanted to attend bingo, and had not been offered activities, while the AC and DON confirmed he required two-person assistance to get up and there was no documentation of attempts to encourage him to attend activities of choice. The activity evaluation also incorrectly showed his goal as met even though he could not join bingo.
A resident with vascular dementia and declining mobility had multiple falls, but the facility did not complete post fall assessments after several of them. Staff said the resident had unsafe unassisted bed exits and needed 1:1 monitoring, and the DON stated post fall assessments were needed to identify the root cause of falls and guide interventions. The facility policy required a post fall assessment for all residents who experienced a fall.
A resident with dysphagia and a gastrostomy was observed lying flat in bed while TF was infusing, despite the care plan directing head-of-bed elevation during feeding and for 30 minutes afterward. An LPN acknowledged the resident should have been positioned with the head of bed elevated to prevent aspiration, and the DON stated the facility’s practice was to keep the head of bed at 30 to 45 degrees during ongoing TF; however, the facility policy did not include positioning guidance.
Failure to Assess Respiratory Status During Nebulizer Treatments: An LPN administered nebulizer treatments to two residents, including one with acute respiratory failure with hypoxia and another with COPD-related nebulizer orders, but did not assess lung sounds, respirations, or heart rate before, during, or after the treatments. The DON and other nurses stated respiratory status and pulse should be checked around breathing treatments, but the LPN said he had not been instructed to do so.
The facility failed to implement a CP’s MRR recommendation for a resident receiving Ativan for anxiety when the ordered behavior to monitor, restlessness, was identified as vague and subjective but was not corrected. The facility also failed to document monitoring for bleeding or bruising for another resident receiving rivaroxaban for stroke prevention for several months, and the CP stated this lack of AC monitoring should have been identified during monthly MRRs.
Improper medication storage and labeling were observed when an LPN found two loose, unlabeled tablets in a medication cart drawer and three expired bisacodyl suppositories in the medication refrigerator. The LPN stated the loose tablets should not have been in the cart because staff would not know what they were used for, and the expired suppositories should not have been stored because they were no longer effective. The DON also stated loose, unlabeled medications were a safety and infection control concern.
Kitchen staff failed to demonstrate proper food safety competencies during direct observation. One CK performed a spoon tilt test on pureed brussels sprouts by repeatedly testing the entire bin and stated she was looking for a pudding consistency, while the DSS said the test should have been done on a plate before serving. Another CK calibrated food thermometers by placing the probes in ice water with the probes touching the bottom of the bin and said she calibrated them every time she checked food temperatures; the DSS stated this was not the correct method and the facility policy required the probe not touch the bottom or sides.
Failure to Document Vaccine Consent and Education: The facility did not have written consents or documented education showing that two residents and their RPs were informed of the risks and benefits of influenza and pneumococcal vaccines when vaccines were accepted or refused. One resident with schizophrenia received an influenza vaccine and declined a pneumococcal vaccine without documented consent, while another resident with schizoaffective disorder refused both vaccines with undated refusals and no documented evidence of consent or education. The ICN and DON both stated that without signed consent, it was not known whether the risks and benefits had been explained.
Missing COVID-19 Vaccine Consent and Education Documentation: The facility failed to maintain written consents and documentation of education for two residents regarding the risks and benefits of accepting or declining the SARS-COV-2 vaccine. One resident with schizophrenia had documentation of receiving the vaccine, but no consent or proof that the resident or RP was educated; another resident with schizoaffective disorder had an undated refusal with no documented education for the resident or RP. The ICN could locate only three of five requested consents, and the DON stated that without a signed consent, the facility could not know whether the RP agreed or whether risks and benefits were explained.
A facility failed to meet the requirement for no more than 4 residents per room when two rooms each housed 5 residents. Observations found residents using wheelchairs and CNAs moving them in and out without difficulty, and interviewed residents reported no complaints about crowding or space. One room’s residents were non-verbal, and the ADM provided a square footage study showing each room had 504 sq ft and 5 beds, with 100.8 sq ft per resident.
A resident with hearing loss was inaccurately assessed as having adequate hearing in the facility's MDS assessments. Despite being deaf and preferring written communication, the assessments indicated no difficulty in normal conversation. Staff interviews revealed discrepancies in the assessment process, with the Case Manager and MDS Coordinator Nurse acknowledging errors in coding.
A resident on parole with an ankle monitor was admitted to a facility without sufficient information to determine if appropriate care could be provided. The facility lacked specific admission criteria and did not screen for parole status, leading to the resident being sent back to the hospital without a medical need. The DON acknowledged the lack of information and screening criteria in the admission process.
A resident on parole with an ankle monitor was improperly discharged from an LTC facility to a hospital without a valid clinical reason. The resident was admitted, given a room, and provided dinner, but was sent back to the hospital the next day after an administrative staff member questioned their parole status. Interviews with staff revealed the facility admitted the resident without proper screening and later decided they were uncomfortable providing care, despite no documentation of danger or medical need for hospital evaluation.
A resident with early onset Alzheimer's and muscle weakness experienced a fall in the shower while assisted by one CNA, despite requiring two staff members for ADLs. The facility failed to update the care plan with interventions to prevent further falls, as identified by the DON.
A resident's clinical records were inaccurately documented, showing administration of Lithium when it was unavailable and misrepresenting behavior monitoring related to Risperidone. Nurses recorded the medication as given despite pharmacy errors and misinterpreted the resident's actions, leading to incorrect behavior documentation.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in care. A resident was not assessed for activities, resulting in boredom, while another with PTSD had a care plan lacking trigger identification. A resident requiring dialysis had an inaccurate care plan referencing a non-existent fistula, and a resident at risk for skin breakdown was not repositioned as required. Staff were unaware of critical care needs, and the facility lacked necessary policies.
The facility failed to ensure safe medication storage and handling, with issues including incomplete temperature logs, food in a medication cart, a discontinued medication not removed, an unlocked medication cart, and a medication left unattended at a resident's bedside. These actions violated facility policies and posed risks to resident safety.
A resident was fed in a manner lacking dignity, as a speech therapist stood above her while feeding, contrary to the facility's policy of maintaining eye-level contact. The therapist, in her clinical fellowship, was unaware of this practice, and no training documentation was found.
A resident with Alzheimer's disease was left exposed in a brief and socks, visible from the hallway, due to a CNA not drawing the curtain or closing the door during personal care. Both the CNA and LN acknowledged the lack of privacy, and the DON confirmed that privacy should have been maintained.
A facility failed to provide activities of interest for a resident with a thoracic vertebra fracture, leading to potential impacts on her well-being. The resident expressed dissatisfaction with the activities, and an activity/interest assessment was not completed as required. The facility's policy to plan activities according to residents' preferences was not followed.
A resident with PTSD did not receive trauma-informed care due to the facility's failure to identify and manage the resident's triggers. Staff interviews revealed a lack of awareness regarding the resident's specific triggers, leading to an inadequate care plan. The facility's policy requires trauma-informed care, but the necessary steps to explore and address the resident's needs were not taken.
A licensed nurse in a LTC facility failed to competently administer medications to a resident, leaving the medication cart unlocked and unattended, and using unlabeled cups for crushed medications. The nurse did not verify vital signs before administering Amlodipine, leading to potential safety risks. The Director of Nursing and Director of Staff Development acknowledged the nurse's incompetence in medication administration.
A facility's medication error rate was 8.33%, exceeding the acceptable limit. An LPN made errors during medication administration for two residents, including incorrect dosages and incomplete administration. The LPN acknowledged not following physician's orders, and the DON confirmed the expectation for adherence to prescribed orders.
A resident was served pureed food and nectar thick beverages without a physician's order, despite being on a mechanical soft diet with thin liquids. The resident expressed dissatisfaction with the meals, and facility staff confirmed the inconsistency. The facility's policy lacked guidance on food texture and beverage consistency.
A resident's medication administration record inaccurately documented the administration of a Lactobacillus capsule, which was not given. LN 10 admitted to the error, acknowledging the active order for the capsule despite discussions of its discontinuation. The DON emphasized the expectation for accurate documentation.
A resident with a g-tube was at risk of infection when an LN attempted to administer medication that had been discarded in the trash. The LN initially failed to dissolve the medication properly, discarded it, and then retrieved it from the trash to administer. A surveyor intervened, and the DON and IPN confirmed the breach of infection control practices.
QAA Failed to Track Medication and Equipment Issues in QAPI
Penalty
Summary
The facility's QAA failed to identify, monitor, and address problem areas identified by the State Survey team for inclusion in the QAPI plan during the annual recertification survey. The deficiency involved medication administration, medication storage, and equipment maintenance issues that had been identified during the survey, but were not listed for implementation or monitoring in the facility's QAPI plan dated 9/10/25 through 12/2025. During interview, the ADM and DON stated they had both started at the facility three months earlier and had reviewed the prior year's recertification findings. They acknowledged that medication administration and medication storage had been issues, and the DON stated she had monitored, audited, and educated staff regarding medication storage and believed the issue had been corrected, so it was dropped from QAPI. The DON also stated that based on the current medication error rate and medication storage issues during the recertification survey, improvement should have been identified before survey. The ADM stated the Director of Maintenance did not attend quarterly QAA meetings, and the DON stated maintenance issues were discussed every morning in stand-up meetings. The ADM acknowledged that equipment safety issues identified during recertification should have been brought to his attention by the Director of Maintenance or the facility's Safety Committee before survey. The facility policy stated the purpose of the QAPI plan and processes was to continually assess performance in all service areas and use feedback, data systems, monitoring, systemic analysis, and systemic action.
Infection Control Program Not Implemented as Required
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program as evidenced by missing documentation for vaccine refusal follow-up education and care planning, no documented hand hygiene surveillance for August, September, and October 2025, and no documented evidence of antibiotic surveillance that included data analysis, length of antibiotic use, appropriate use, or communication with the Medical Director and pharmacist. The facility’s Infection Control Prevention and Control Program stated that infection surveillance and reporting, as well as monitoring and documenting compliance with infection prevention practices such as hand hygiene, were part of the program. During interview, the DSD/IP stated she had no access to CAIR and could not check residents’ vaccination status, and the DSD/IP and DIT could not verbalize what action was needed to correct the decline in hand hygiene adherence. Resident 178 was admitted with diagnoses including acute respiratory failure with hypoxia. During observation, the resident was in bed with an oxygen cannula connected to a humidifier bottle and concentrator, and the oxygen tubing did not have a date. During a joint observation and interview, LN 14 stated the tubing did not have a date for when it was last changed and stated it should be dated when first applied and changed every Wednesday to keep it clean and prevent infection. Resident 8 was admitted with diagnoses including dysphagia and gastrostomy status. During observation, an oxygen cannula was hanging on top of the concentrator and a nebulizer mask was on top of the bedside table. The resident’s order summary indicated the oxygen nasal cannula and plastic storage bag were to be changed every Wednesday night and as needed. During interview, LN 14 stated the oxygen tubing and nebulizer mask were not stored in a plastic bag and should be stored in a plastic bag when not in use to keep them clean and prevent resident infection. LN 12 and the DON also stated oxygen cannulas and nebulizer masks should be dated when changed and stored in a plastic bag for infection control.
Failure to Assist Dependent Residents With ADLs
Penalty
Summary
The facility failed to provide assistance with activities of daily living for dependent residents in several areas, including getting a resident out of bed, cueing cognitively impaired residents for hand hygiene before meals, and providing routine nail care. The report states that 6 of 6 dependent residents were affected. The cited policy required residents who are unable to carry out ADLs to receive assistance as needed. Resident 23 was readmitted with multiple sclerosis and was assessed as dependent on staff for ADLs, including transfers. His care plan stated he required total assistance with transfers. During multiple observations and interviews, he was found lying in bed, stated he could not stand or walk, and said he had not been gotten up from bed. Staff interviews confirmed he required two-person assistance to transfer from bed to wheelchair and back, and staff acknowledged he had been in bed a lot. Two cognitively impaired residents, one with severe dementia and one with moderate cognitive impairment, were observed during dining without hand hygiene being provided before meals. One resident handled food with bare hands and licked her fingers, and the other licked his fingers while eating. Staff later stated the residents required supervision and cueing for hand hygiene and that hand hygiene should have been offered before and after meals. Three other residents had long fingernails that were not maintained as described in the report. One resident with MS and hand contractures had long, sharp fingernails and said he wanted them trimmed. Another resident with MS had long fingernails with black debris under them and said he could not trim them himself. A third resident with hemiplegia and hemiparesis had long fingernails while his hands were contracted and closed, and staff stated nail care was important for hygiene and infection control.
Delayed notification for bleeding signs and unauthorized blood sugar checks
Penalty
Summary
Timely assessment, monitoring, and physician notification were not ensured for a resident who had significant clinical changes, including coffee ground emesis and later a change in level of consciousness. The resident had been readmitted with pneumonia and had a history and physical noting a large left chest wall hematoma with active extravasation on CT and use of enoxaparin. Nursing documentation showed coffee ground emesis at about 1:36 A.M. and again later in the morning, but the record and staff interviews indicated there was no documented assessment before ondansetron was given and no documented immediate notification of the physician or NP at the time of the change in condition. Interviews with the DON and LN staff indicated the physician/NP was not notified until many hours after the first observed coffee ground emesis, and the DON stated the nurses should have notified the physician immediately because the resident was on anticoagulant therapy and coffee ground emesis could indicate bleeding. The DON also stated there was no documentation of monitoring for further bleeding and no documentation of notifying the doctor when the emesis was first observed. Later that morning, the resident had a change in level of consciousness, the NP was notified, CPR was initiated at the facility, and the resident was transferred to the hospital, where the resident later expired. A separate deficiency involved blood sugar checks for another resident who was receiving insulin. Staff observed a blood glucose check being performed even though the current physician orders did not include blood sugar checks. LN interviews confirmed there was no physician order for the checks and that staff should have clarified the order with the supervisor or physician. The record review also showed multiple blood sugar checks were performed at close intervals, and the DON stated nurses should not check blood sugar without a physician order and did not know why the checks were taken so close together.
Failure to Monitor Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary drugs when Resident 5 was receiving rivaroxaban for prevention of stroke and was not monitored for signs and symptoms of bruising or bleeding for five months. Resident 5 was re-admitted with diagnoses that included hemiplegia and hemiparesis following a stroke, and the clinical record showed a physician's order for rivaroxaban beginning on 7/31/25. A review of the record on 12/15/25 found no physician's order or documentation of monitoring for signs and symptoms of bleeding or bruising related to rivaroxaban use from 7/31/25 through 12/14/25. During interview, LN 3 stated Resident 5 had been receiving rivaroxaban throughout August, September, October, November, and until 12/14/25, and that there was no documentation of monitoring until 12/15/25. LN 3 stated the resident should have been monitored for bruising and bleeding because the resident was unable to express symptoms. The DON stated the expectation was for LNs to monitor residents receiving anticoagulants for signs of bleeding and bruising, and the facility policy stated residents are monitored for bleeding.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent; the observed medication error rate was 19.51%, with eight medication errors identified out of 41 opportunities during medication administration for one of eight randomly observed residents. During the observation, a nurse administered Tylenol 325 mg two tablets by mouth, Allopurinol 100 mg by mouth, Carvedilol 12.5 mg by mouth, Hydralazine hydrochloride 25 mg by mouth, Metformin hydrochloride 850 mg by mouth, a multivitamin with mineral by mouth, Geri-Kot 8.6 mg two tablets by mouth, and Juven nutrition powder mixed in water by mouth to a resident who had been admitted with dysphagia and gastrostomy status. A review of the order summary for the resident showed that the ordered routes for these medications were via G-tube or enterally, not by mouth. The orders listed Tylenol, Allopurinol, Carvedilol, Hydralazine hydrochloride, Metformin hydrochloride, multiple vitamins-minerals, Senna, and Juven to be administered through the feeding tube or enterally. During interviews, one nurse stated the MAR should be checked before administration to ensure the correct medication, resident, dose, time, and route, and the administering nurse acknowledged that the physician's orders for the tablets were to be given via the resident's G-tube. The DON stated nurses were expected to follow the five rights of medication administration, and the facility policy stated medications should be accurately prepared, administered, and documented, but it did not provide guidance regarding the five rights.
Incomplete Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to follow its own Antibiotic Stewardship policy when the Infection Preventionist did not comprehensively track and monitor antibiotic use. During interview and record review, the Director of Staff Development, who had started in the Infection Preventionist role on 12/11/25, the DON in training, and the DON stated that the facility had transitioned on 10/16/25 and the designated Infection Preventionist was no longer working there. The October 2025 antibiotic surveillance showed 6 cases of community acquired infection and 6 cases of healthcare associated infection, while the October 2025 case mapping contained 8 entries but did not identify whether the cases were community acquired or healthcare associated. The antibiotic surveillance did not match the case map for October 2025. There was no documented evidence of comprehensive tracking measures for antibiotic use, including data analysis, length of antibiotic use or number of days of therapy, or the reason for using the antibiotic. There was also no evidence of communication with the Medical Director and Pharmacist to discuss opportunities for improvement. The DSD/IP, the DIT, and the DON could not discuss the Infection Control Program. The facility policy titled Antibiotic Stewardship, revised 9/2017, stated that the facility would implement an Antibiotic Stewardship Program incorporated into the Infection Prevention and Control Program and that nursing home ASP activities should include leadership, accountability, drug expertise, action, tracking measures, reporting data, and education.
Unsafe Resident Equipment and Peeling Handrails
Penalty
Summary
The facility failed to maintain resident equipment in a safe, functional manner for 57 of 159 residents in the secured unit when hallway handrails at Station 3 had peeling paint and a resident bed remote control had exposed wires. During an initial tour, the handrails outside a resident room were observed with numerous layers of paint and white paint peeling in different areas. The Director of Maintenance later observed and removed patches of peeling paint from the handrails and stated he checked them daily because of the peeling paint. Licensed Nurse 33 later stated the handrails had been painted overnight because the previous paint kept peeling, and that the green paint was already starting to peel because too much paint had been added. A handrail in Station 2’s hallway was also observed with a small area of chipped wood exposed. Resident 4, who had diagnoses including paranoid schizophrenia, was observed lying in bed with the bed control remote wrapped around the upper right side rail. The coiled cord to the remote was frayed with exposed wires about 6 to 7 inches down the length of the cord. CNA 33 stated the cord should be replaced because wires were exposed and that the exposed wires were a safety issue that could poke the resident. The frayed cord had not been reported by staff and was not documented in the unit’s maintenance book. The Director of Maintenance stated he conducted monthly inspections of resident rooms but could not identify when Resident 4’s room was last inspected in his monthly maintenance log, and later stated he was informed that day of the exposed wires. The DON stated she expected all resident equipment to be regularly inspected to be safe and functional.
Failure to Maintain Resident Dignity During Personal Care and Mealtime Assistance
Penalty
Summary
The facility failed to promote dignity for two residents when a urinary collection bag was left uncovered and visible, and when a staff member stood over a resident while assisting with a meal. Resident 177 had been readmitted after a hospital stay for bacteremia and, during an observation in the resident’s room, had a milliliter-type urinary drainage bag hanging from the bedframe with urine visible inside it and no dignity bag covering it. The nurse observing the resident stated the drainage bag should have been covered, and the DON stated all urinary collection bags were expected to be covered to promote privacy and dignity. Resident 4, who had diagnoses including paranoid schizophrenia, was observed in bed while a CNA assisted with breakfast. The CNA stood next to the bed and over the resident’s head by approximately 2 feet while feeding her. The CNA stated she should not have been standing over the resident because it was a dignity issue. Other staff stated that staff should maintain eye level when assisting residents with meals, and the DON stated staff should always maintain eye-to-eye level to promote dignity and respect.
Delayed Physician Notification for Coffee Ground Emesis
Penalty
Summary
The facility failed to ensure a licensed nurse notified the physician immediately when a resident on anticoagulant therapy had episodes of large coffee ground emesis. Resident 1 was readmitted with diagnoses including pneumonia, and the history and physical noted a chest wall large hematoma with active extravasation on CT and that enoxaparin was among the active medications. Nursing progress notes documented large coffee ground vomiting at 1:36 A.M. and again around 3:00 A.M., but the record review and interviews indicated there was no documentation that the physician or nurse practitioner was notified at that time. During the joint record review, the DON stated the nurse practitioner was not notified until 10:20 A.M. to 11:10 A.M., more than eight hours after the change in condition was first observed. The DON also stated the nurses should have notified the physician immediately because the resident was on anticoagulant therapy and coffee ground emesis was a sign of bleeding. The resident later had a change in level of consciousness, was sent to the hospital after CPR was initiated at the facility, and expired at the hospital.
Incomplete investigation of abuse allegation
Penalty
Summary
The facility failed to ensure a thorough investigation was conducted for an allegation of abuse involving one resident who reported that a male restorative nursing assistant inappropriately touched her breast. The allegation was first reported to CDPH on 12/2/25. During a concurrent observation and interview, the resident was found curled up in bed and stated that the staff member touched her breast in her room, although she could not recall the date and time. She also stated there were two unwitnessed incidents involving the same staff member and that she told her roommate about the second incident. The roommate stated the incident happened a couple of weeks earlier after breakfast in the room and that she heard the resident saying, "it is not happening," but did not witness the event. The DON later reviewed the resident's records and the staff member's record and stated the resident's H&P indicated she lacked capacity to understand and make decisions, and her BIMS score was 5/15, showing severe cognitive impairment. The DON also stated the staff member had no prior allegations, suspensions, or disciplinary actions and was current with trainings. During follow-up interview, the DON stated the investigation did not document dates and times for interviews with the resident, roommate, or staff member, and no other residents or staff who had contact with the accused employee were interviewed. The facility policy required interviews with staff on all shifts, other residents who may have information, staff with contact with the accused employee, and a review of all circumstances surrounding the incident.
Missing Written Transfer and Bed Hold Notice
Penalty
Summary
The facility failed to provide a written notice of transfer and its bed hold policy to a resident and his Responsible Party at the time the resident was transferred to an acute care hospital. Resident 18 was readmitted to the facility with diagnoses including end stage renal disease, and his history and physical stated he did not have the capacity to understand and make decisions, with a family member serving as the Responsible Party. A progress note documented that Resident 18 was transferred to an acute care hospital for a change in condition, but there was no documentation that the Responsible Party was given written notice of the transfer or the facility's bed hold policy. The bed hold notification form signed at admission was incomplete, with the sections for the hospital destination, day and time of transfer, who notified the resident or Responsible Party, when notification occurred, and staff signature left blank, and the 24-hour notification section was also blank. The DON stated there was no signature when the resident was transferred out and that written notice of transfer and bed hold should have been provided because it was the resident's right.
Inaccurate MDS Coding for Restorative Nursing and Resident Status
Penalty
Summary
The facility failed to accurately assess and code Restorative Nursing Services (RNA) on the MDS for two residents. For one resident admitted with diagnoses including cerebral infarction affecting the left side, the record showed a physician order for passive ROM to the left lower extremity three times a week, weekly restorative nursing notes, and a care plan stating RNA services were being provided three times a week. During an initial tour, the resident was observed in bed with a wheelchair nearby and stated he wanted physical therapy because he could not walk and felt he was getting weaker every day. The MDS for that resident, dated 12/11/25, indicated no restorative nursing programs had been provided in the prior seven days. During review, the MDSN stated she checked the physician orders and the RNA administration record, but the administration record had no documented services. RNA 1 then stated he documented services in nursing progress notes and did not use the RNA administration record. The MDSN stated she missed the services by not checking the nursing progress notes and acknowledged that CMS was not informed of the resident’s current condition and services being provided. For the second resident, the record showed a history of stroke with left-sided hemiplegia, but the admission and readmission assessments were inconsistent. One assessment documented weakness, paralysis, and ROM limitation on the left side, while another later assessment indicated no weakness, no paralysis, and no ROM limitation or loss. During interview and record review, LN 21, LN 22, and the MDSN each stated the resident’s record and MDS assessment were not accurate. The DON also stated the resident’s records were not coded accurately and that accurate MDS coding was needed to provide accurate care.
PASRR II Not Completed for Resident With Schizophrenia
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed in a timely manner for one resident who was admitted with schizophrenia. The resident’s record showed a PASRR I completed on 11/10/25 that was positive and triggered a PASRR II by a State official, but there was no documented evidence that the PASRR II had been completed when the record was reviewed. A review of the PASRR II document showed it was dated 11/14/25 and stated, "Unable to complete evaluation for serious Mental illness. Staff were unresponsive on 2 or more attempts to schedule within 48 hrs. Case close." During interview, the MDS Nurse stated she arranged and scheduled PASRR II interviews with State evaluators, but after reviewing the document she realized the PASRR II had never been completed. The DON stated PASRR II's were important so staff could properly care for the resident and provide all recommended services, and the facility policy required PASRR completion on every resident upon admission and referral to appropriate State agencies based on the assessment.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized therapeutic and social activities that matched Resident 23’s plan of care and preferences. Resident 23 was readmitted with multiple sclerosis and, according to the MDS, could make independent reasonable decisions but had lower extremity impairment and was dependent on staff for ADLs and transfers. The care plan stated he would participate in group activities of choice, including bingo. During observations and interviews, Resident 23 stated he stayed in bed, could not stand or walk, needed assistance to get up, wanted to join activities, and had not been offered activities. He said he had not gone to activities, wanted to play bingo, and reported that it was boring and that staff had not offered him any activities. Staff interviews and record review showed Resident 23 required two-person assistance to transfer from bed to wheelchair and back, and the Activity Coordinator stated he was in a one-on-one activity program from November to December 2025. The Activity Coordinator also stated Resident 23 liked bingo, but bingo was a group activity and the quarterly activity evaluation incorrectly indicated his goal was met even though he could not join bingo. The Activity Coordinator stated Resident 23 had no wheelchair to attend the group activity and that the information had been communicated to nursing, but she could not locate documentation showing he needed a wheelchair to attend. The DON stated there was no documentation of an attempt to encourage Resident 23 to attend activities of choice, and the facility policy required a resident-centered activities program based on resident interests, preferences, needs, and abilities.
Failure to Complete Post Fall Assessments
Penalty
Summary
The facility failed to complete post fall assessments for Resident 57 after multiple fall incidents, contrary to its policy requiring a post fall assessment for all residents who experienced a fall. Resident 57 was admitted with vascular dementia and had a history of declining mobility, previously walking with a front wheel walker but later preferring to stay in bed most of the day. During observation, Resident 57 was in bed with a floor mat on the right side of the bed. Staff interviews indicated the resident had multiple falls, including on 9/3/25, 9/16/25, 10/11/25, 11/5/25, 12/8/25, and 12/11/25. Record review and staff interviews showed fall risk assessments were completed after some falls, but not after the falls on 9/3/25, 11/5/25, and 12/8/25. LN 11 stated the missing assessments should have been completed to evaluate the resident's functionality and whether fall preventive measures were working. CNA 13 stated Resident 57 had episodes of unsafely getting up from bed unassisted and required one-on-one monitoring for safety. The DON stated post fall assessments were needed to check the root cause of a fall and to have appropriate interventions. The facility's Fall Best Practice Guidelines required investigation of each fall and completion of a post fall assessment with recommendations and care plan changes for all residents who experienced a fall.
Improper positioning during tube feeding
Penalty
Summary
The facility failed to ensure that Resident 5 was positioned properly while tube feeding was infusing, despite the resident’s plan of care directing that the head of bed be elevated to 45 degrees during tube feeding and for 30 minutes afterward. Resident 5 was re-admitted to the facility on 7/29/25 with diagnoses including dysphagia and a gastrostomy. During an observation on 12/16/25 at 9:38 A.M., Resident 5 was found lying flat in bed while tube feeding was running. During a joint observation and interview on 12/16/25 at 10:40 A.M., LN 32 stated the tube feeding would have been completed at 10:00 A.M. and acknowledged that the resident’s head of bed was flat and should have been elevated to prevent aspiration that could have led to pneumonia. LN 32 stated that for residents receiving ongoing tube feeding, the head of bed should be elevated to 30 to 45 degrees. The DON later stated the facility’s policy for residents with ongoing tube feeding was to elevate the head of bed to 30 to 45 degrees to prevent aspiration. A review of the facility’s Gastrostomy Tube Care and Management policy dated 1/22 did not include guidance on proper positioning of a resident receiving tube feeding.
Failure to Assess Respiratory Status During Nebulizer Treatments
Penalty
Summary
The facility failed to assess respiratory status during nebulizer treatments for two residents. Resident 178 was admitted with acute respiratory failure with hypoxia. On 12/17/25 at 8:55 A.M., the resident’s family member told LN 14 that Resident 178 was having difficulty breathing, and LN 14 stated he would give a nebulizer treatment. LN 14 prepared the medication, placed a mask on the resident, and turned on the machine, but did not listen to lung sounds or check respiratory rate or heart rate before, during, or after the treatment. The order summary listed Ipratropium-Albuterol Solution 3 ml inhaled three times a day for acute respiratory failure. Resident 8 was admitted with diagnoses including dysphagia and gastrostomy status. During a medication administration observation on 12/17/25 at 9:52 A.M., LN 14 stated Resident 8 was due for a nebulizer treatment. LN 14 poured Budesonide inhalation suspension into the nebulizer chamber, applied the mask, and started the machine, but did not check lung sounds, respiratory rate, or heart rate before, during, or after the treatment. LN 14 stated he was not instructed to check respiratory rate and pulse prior to, during, or after a nebulizer treatment. Other staff and the DON stated respirations, breathing, pulse, and lung sounds should be checked before and after nebulizer treatments, and the DON stated nurses should stay with the resident during breathing treatment and assess for abnormality and effectiveness.
Failure to Implement MRR Recommendation and Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to address and implement the Consulting Pharmacist’s recommendation from the monthly Medication Regimen Review for a resident with paranoid schizophrenia who was receiving Ativan 1 mg three times daily for anxiety. The physician’s order directed staff to monitor episodes of anxiety as exhibited by restlessness every shift, and the care plan included monitoring and recording target behavior occurrences. During the October 2025 MRR, the CP noted that “restlessness” was vague and subjective and asked that it be changed or corrected, but there was no documented evidence that the recommendation was addressed or acted on. Facility nurses and the DON stated that the behavior was too vague and should have been made more specific for staff monitoring, and the DON acknowledged that the recommendation was not followed through. The facility also failed to monitor a resident receiving rivaroxaban for signs and symptoms of bleeding or bruising for five months. The resident had diagnoses including hemiplegia and hemiparesis following a stroke and had a physician’s order for rivaroxaban for stroke prevention. Review of the clinical record showed no physician’s order and no documentation of monitoring for bleeding or bruising from the start of therapy through mid-December 2025. A nurse confirmed that the resident had been receiving rivaroxaban during that entire period and that there was no documentation of monitoring until the order appeared later. The nurse stated the resident should have been monitored for bruising and bleeding for safety because the resident was unable to express symptoms. The CP stated that the anticoagulant therapy should have been reviewed monthly for discrepancies and that the lack of monitoring for untoward side effects should have been captured during the MRR, but it was not. The DON stated the expectation was for nurses to monitor residents on anticoagulants for bleeding and bruising. Facility policy required monthly pharmacist review of each resident’s medication regimen to identify clinically significant risks or adverse consequences, and the anticoagulant policy stated that residents are monitored for bleeding and that anticoagulant therapy is reviewed monthly by the consultant pharmacist with follow-up documented as appropriate.
Improper Medication Storage and Labeling
Penalty
Summary
Medications were found improperly stored and labeled during a medication storage observation. At station 1, a licensed nurse opened the second drawer of the medication cart and two loose, unlabeled tablets were found at the bottom of the drawer. The nurse stated she was unsure why the tablets were there and confirmed that medications in the cart should not be loose and unlabeled because staff would not know what they were used for. During a separate observation in the medication storage room, three bisacodyl suppositories were found inside the medication refrigerator. The licensed nurse checked the expiration dates and stated the suppositories had an expiration date of 11/2025 and should not have been in the refrigerator because they were expired. The DON later stated there should be no loose and unlabeled medications in the medication drawer because it was a safety issue and infection control concern, and that expired medications were no longer effective. The facility policy required medications and biologicals to be labeled in accordance with facility requirements, state and federal laws, and stated that drugs shall be stored in appropriate temperatures.
Kitchen Staff Competency Deficiencies in Puree Testing and Thermometer Calibration
Penalty
Summary
The facility failed to ensure kitchen staff carried out food and nutrition service tasks in accordance with standard practice for two kitchen competencies. During a joint observation, CK 1 performed a spoon tilt test on pureed brussels sprouts by taking the puree from a metal bin, repeatedly scooping it, returning it to the same bin, and mixing it several times while stating she was looking for a pudding consistency. CK 1 later stated she should have done the spoon tilt test on a plate instead of testing the whole bin of pureed food. The Dietary Services Supervisor stated CK 1 had in-service training in August and September 2025 and should have performed the test in a plate prior to serving to maintain the texture of the whole container of pureed food. During another joint observation, CK 2 attempted to calibrate food thermometers by placing three thermometers in a metal bin with ice and water and leaving the probes submerged with the probes touching the bottom of the bin. CK 2 stated she would start the tray line and said she calibrated the thermometer every time she checked cooked food temperatures. The Dietary Services Supervisor stopped CK 2 and stated she did not have to calibrate the thermometer every time she checked temperatures. The supervisor later stated CK 2 had in-service training on thermometer calibration on 11/7/25, but did not demonstrate proper calibration because the probes should not touch the bottom or sides of the bucket. The facility policy titled Thermometer Use and Calibration stated the thermometer stem must be placed in ice water without touching the bottom or sides of the glass during calibration.
Failure to Document Vaccine Consent and Education
Penalty
Summary
The facility failed to obtain written consents and documented education showing that residents and their responsible persons were informed of the risks and benefits of receiving or declining influenza and pneumococcal vaccines for two of five residents reviewed. Resident 121, who was admitted with schizophrenia and had a documented Durable Power of Attorney for medical consent only, had an immunization record showing an influenza vaccine was given and a pneumococcal vaccine was declined, but there was no documented evidence that the resident or the RP consented to the influenza vaccine or that the risks of declining the pneumococcal vaccine were explained. Resident 14, who was admitted with schizoaffective disorder and also had a Durable Power of Attorney for medical consent only, had immunization documentation showing refusal of both influenza and pneumococcal vaccines, but both refusals were undated and there was no documented evidence that the resident or the RP consented to vaccination or that the risks were explained. During interview, the acting Infection Control Nurse stated she could only locate three of the five requested vaccination consents in the binder kept in the ICN office, and stated that without signed consent it was not known whether the risks or benefits of vaccination had been explained to the residents and their RPs. The DON stated that without a signed consent, it was not known whether the RP agreed to vaccination or whether the risks and benefits were explained to the resident and RP. The facility policy titled Immunizations-Residents required residents or their representatives to receive education regarding the benefits and potential side effects of immunization and to document that the education was provided.
Missing COVID-19 Vaccine Consent and Education Documentation
Penalty
Summary
The facility failed to obtain written consents and documented education showing that residents and their responsible persons were informed of the risks and benefits of receiving or declining the SARS-COV-2 vaccine for two of five residents reviewed. Resident 121, who was admitted with schizophrenia and had a Durable Power of Attorney for medical consent only, had documentation showing receipt of the SARS-COV-2 vaccine on 12/4/25, but the clinical record contained no consent or evidence that the resident or RP received education about the risks and benefits of accepting or declining the vaccine. Resident 14, who was admitted with schizoaffective disorder and also had a Durable Power of Attorney for medical consent only, had an immunization record showing refusal of the SARS-COV-2 vaccine, but the refusal was undated and there was no documented evidence that the resident or RP received education about the risks and benefits of accepting or declining the vaccine. The acting ICN stated she could locate only three of the five requested consents in the binder kept in the ICN office, and the DON stated that without a signed consent, the facility did not know whether the RP agreed to vaccination or whether the risks and benefits were explained.
Excess Residents in Two Shared Rooms
Penalty
Summary
The facility failed to meet the requirement for accommodating no more than four residents per resident room. Two of 65 resident rooms, room [ROOM NUMBER] and room 112, each housed five residents. On multiple observations from 12/15/25 through 12/18/25, the five male residents in room [ROOM NUMBER] and the five female residents in room [ROOM NUMBER] were observed in the rooms, and there were no observed problems with the provision of care. CNAs were able to wheel residents in and out of the rooms without difficulty, and residents were seen using wheelchairs. During interviews on 12/18/2025, residents in room [ROOM NUMBER] reported no complaints about the number of residents in the room or concerns about space. Attempts to interview the five residents in room [ROOM NUMBER] were unsuccessful because all were non-verbal and did not respond to questions. The ADM provided the Square Footage Study dated December 2025, showing no change in square footage since 2019; both rooms contained 504 total square feet and five beds, with 100.8 square feet per resident. The report stated there were no indications of adverse effects on quality of care, quality of life, or health and safety, and that the rooms were in accordance with the special needs of the residents occupying them.
Inaccurate Resident Hearing Assessment
Penalty
Summary
The facility failed to accurately code the required resident assessment for a resident, which had the potential to not identify the resident's needs. The resident was admitted with health conditions requiring assistance with personal care and unspecified hearing loss. During an unannounced visit, it was found that the resident was deaf and preferred written communication, which she responded to verbally. However, the facility's MDS assessments inaccurately indicated that the resident's hearing was adequate, showing no difficulty in normal conversation or social interaction. Interviews with facility staff revealed discrepancies in the assessment process. The Case Manager acknowledged that the MDS assessments were expected to be completed in person, but a mistake was made in the coding of the resident's hearing ability. The MDS Coordinator Nurse confirmed signing off on the assessments but could not recall why the resident's hearing was coded as adequate. The Social Worker responsible for the most recent assessment was unavailable for comment, leaving the error unexplained.
Failure to Implement Admission Policy for Resident with Parole Status
Penalty
Summary
The facility failed to implement its admission policy when a resident was admitted without sufficient information to determine if appropriate care and services could be provided. The resident, who was on parole and wore an ankle monitor, was admitted to the facility and later sent back to the hospital without a medical need for hospital treatment. The facility's admissions coordinator stated that the facility did not have specific admission criteria and did not screen for parole status or criminal background, although they had previously admitted residents with similar backgrounds. The director of nursing acknowledged that the facility did not have sufficient information about the resident's parole status and that the hospital did not disclose this information. The facility's admission process lacked criteria to screen for residents with criminal history or those on parole, which led to the resident being admitted without proper screening. The facility's policy indicated that admission decisions should be based on the ability to meet the medical and psychosocial needs of the resident, but this was not followed in this case.
Improper Discharge of Resident Without Valid Clinical Reason
Penalty
Summary
The facility failed to ensure that a resident was permitted to remain in the facility when they were discharged to the hospital without a valid clinical reason. The resident, who was on parole and wearing an ankle monitor, was admitted to the facility, given a room and bed, and provided dinner. The next morning, an administrative staff member questioned the resident about their parole status and ankle monitor, subsequently informing the resident that they could not stay at the facility and would have to return to the hospital. The resident was then transported back to the hospital, despite not having a medical need that required hospital treatment. Interviews with facility staff, including the admissions coordinator, licensed nurse, and director of nursing, revealed that the facility had admitted the resident without properly screening them and later decided they were not comfortable providing care. The facility's policy states that a resident should not be transferred or discharged unless it is necessary for their welfare, their health has improved, or the safety and health of others in the facility are endangered. However, there was no documentation indicating that the resident posed a danger to themselves or others, nor was there a medical situation necessitating hospital evaluation.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan with resident-specific interventions for a resident who was reviewed for falls. The resident, who was admitted with diagnoses including muscle weakness, cognitive communication deficit, and early onset Alzheimer's disease, was dependent on staff for showering. The Minimum Data Set (MDS) indicated that the resident required the assistance of one staff member for activities of daily living (ADLs) prior to a fall incident. However, after the fall, it was determined that the resident required two staff members for assistance. The deficiency was identified when the resident reported a fall in the shower while sitting in a shower chair, with only one Certified Nursing Assistant (CNA) present. The Director of Nursing (DON) identified the root cause of the fall as a sudden movement by the resident and stated that interventions to prevent further falls included providing bed baths instead of showers and educating the resident and staff. Despite these findings, the resident's care plan was not updated with the necessary interventions to address the root cause of the fall, as required by the facility's Falls Prevention policy.
Inaccurate Documentation of Medication and Behavior Monitoring
Penalty
Summary
The facility failed to ensure accurate documentation in the clinical record for a resident who was prescribed Lithium, a mood stabilizing medication. The resident's medication administration record (MAR) inaccurately indicated that Lithium was administered on multiple occasions when the medication was not available due to a pharmacy error. The pharmacy had not dispensed the medication because they believed the resident was allergic to it. Despite this, licensed nurses documented that the medication was given, which was later acknowledged as an error by the nurses involved. Additionally, the facility failed to accurately document the resident's behavior monitoring associated with the administration of Risperidone, an antipsychotic medication. The MAR inaccurately recorded episodes of the resident striking out toward others, which was not observed by the nurses. Instead, the resident was seen swinging his amputated arm in a manner that was misinterpreted as aggressive behavior. The nurses admitted to documenting these actions inaccurately, which did not reflect the true nature of the resident's behavior. The director of nursing acknowledged the inaccuracies in the documentation and confirmed that the Lithium was not dispensed until a later date. The facility's policy on charting and documentation did not provide guidance on ensuring the accuracy of documentation, contributing to the deficiencies observed in the resident's clinical records.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for several residents, leading to deficiencies in care. Resident 47, who was admitted with a fracture of the thoracic vertebra, was not assessed for activities, resulting in a lack of engagement and boredom. The Activity Director admitted that an activity/interest assessment was not completed within the required timeframe, and the care plan did not address the resident's preferences for activities. This oversight was acknowledged by the facility's consultant, who noted the need for a more thorough assessment. Resident 42, diagnosed with Post-Traumatic Stress Disorder (PTSD), had a care plan that failed to identify specific triggers for re-traumatization. Interviews with various staff members, including the Assistant Director of Nursing and a Certified Nursing Assistant, revealed that none were aware of the resident's triggers, which were crucial for providing appropriate care. The facility's consultant recognized the inadequacy of the care plan, noting that the resident's triggers should have been explored more thoroughly. Resident 32, who required dialysis, had a care plan that inaccurately referenced an arteriovenous fistula, despite the resident having a permacath for dialysis access. Licensed nurses were incorrectly documenting care related to a fistula, which the resident did not have. The Director of Nursing confirmed the inaccuracies in the care plan, emphasizing the importance of having resident-specific and accurate care plans to prevent miscommunication and errors. Additionally, Resident 43, who was at risk for skin breakdown, was not turned and repositioned every two hours as required by their care plan, with staff failing to implement this critical intervention. The facility lacked a policy on turning and repositioning, further contributing to the deficiency.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and handling of medications, as evidenced by several observations and interviews. The medication refrigerator temperature log was found to be incomplete, with missing entries for two consecutive days. This lack of documentation raised concerns about whether medications were stored at the correct temperature, potentially affecting their efficacy. Additionally, a food product was discovered in a medication cart, which could lead to cross-contamination with medications. The facility's policy on medication storage emphasizes the importance of maintaining clean and clutter-free storage areas, which was not adhered to in this instance. Further deficiencies were noted when a discontinued medication was not removed from a medication cart, posing a risk of accidental administration. A medication cart was also left unlocked and unattended by a licensed nurse, which could allow unauthorized access to medications. The facility's policy requires medication carts to be locked when out of sight, a protocol that was not followed in this case. These lapses in medication management highlight a failure to adhere to the facility's policies and procedures, potentially compromising resident safety. In another incident, a medication was left unattended at a resident's bedside, which is against the facility's policy of keeping medications secure. The licensed nurse involved acknowledged the mistake, noting that other cognitively impaired residents in the room could have accessed the medication. The Director of Nursing confirmed that medications should not be left unattended at any resident's bedside, underscoring the importance of maintaining control over medication administration to prevent potential harm.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was assisted with a meal in a dignified manner. Resident 106, who was readmitted with a diagnosis including epilepsy, was observed being fed by a staff member in a manner that did not maintain eye-level contact. The staff member, identified as Speech Therapist 1 (ST 1), was standing approximately two feet above the resident's head while feeding her a pureed diet. ST 1 was conducting a swallowing skills assessment and admitted to not being informed about the importance of feeding residents at eye level. Interviews with other staff members, including Licensed Nurse 31 (LN 31) and Physical Therapy Assistant 1 (PTA 1), confirmed that maintaining eye-level contact while feeding is a standard practice to promote resident dignity. It was revealed that ST 1 was in her clinical fellowship and there was no documented evidence of her receiving training on proper feeding techniques. The Director of Nursing (DON) also emphasized the expectation for staff to maintain eye level during meal assistance, aligning with the facility's policy on dignity and privacy.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy for a resident during personal care, as observed by surveyors. The resident, who was admitted with Alzheimer's disease and was severely cognitively impaired, was left visible from the hallway while wearing only a brief and socks on the lower half of his body. This occurred when a certified nursing assistant (CNA) left the room carrying a bag of soiled items without drawing the curtain or closing the door, leaving the resident exposed to passers-by. Interviews with the licensed nurse (LN) and the CNA involved confirmed that privacy should have been provided by drawing the curtain and closing the door. Both staff members acknowledged that the resident was unable to verbalize his feelings due to confusion, and they expressed that the situation was undignified. The director of nursing (DON) also confirmed that privacy should have been maintained during the resident's personal care, in accordance with the facility's policy on dignity and privacy.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide activities of interest for a resident, identified as Resident 47, which had the potential to impact her physical, mental, and psychosocial well-being and independence. Resident 47 was admitted with a diagnosis of a fracture of the thoracic vertebra. During an observation and interview, Resident 47 expressed boredom and dissatisfaction with the activities offered, describing them as suitable for young children. The Activity Director admitted that an activity/interest assessment was not completed within the required five days after admission. The resident's activities care plan indicated minimal involvement in activities and a stated wish not to participate, which was not adequately addressed. The facility's policy requires activities to be planned according to residents' preferences, needs, and abilities, but this was not followed in Resident 47's case.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), as required by professional standards of practice. The resident, identified as Resident 42, was admitted with a diagnosis of PTSD, which necessitates careful management to prevent re-traumatization. However, the facility did not identify the resident's triggers, which are crucial for providing appropriate care. Interviews with various staff members, including the Assistant Director of Nursing, a certified nursing assistant, a registered nurse, and the Director of Staff Development, revealed that none of them were aware of the resident's specific triggers. This lack of knowledge indicates a failure to implement a comprehensive care plan tailored to the resident's needs. The facility's policy on Behavioral Health Services emphasizes the importance of providing trauma-informed care to prevent re-traumatization. Despite this policy, the care plan for Resident 42 was found to be inadequate, as acknowledged by the facility's consultant and administrator. The consultant noted that the facility should have explored the resident's diagnosis and potential triggers more thoroughly, especially since the resident and their family were unable to provide this information. This oversight resulted in the potential for the resident to lack a sense of emotional and physical safety, as the facility did not take necessary steps to identify and mitigate possible triggers.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a licensed nurse (LN 10) was competent in medication administration, which led to several deficiencies during the administration of medications to Resident 43. LN 10 left the medication cart unlocked and unattended, which is against the facility's policy. During the medication administration, LN 10 crushed several medications into powder and placed them in unlabeled cups, leading to confusion about which medication was which. LN 10 attempted to administer a medication that had been discarded in the trash, which was stopped by the surveyor due to infection control concerns. Resident 43, who had a history of hemiplegia, hemiparesis, hypertension, dementia, and a gastrostomy, was at risk due to LN 10's actions. LN 10 did not verify the resident's vital signs before administering Amlodipine, which had specific hold parameters based on blood pressure and heart rate. The vital signs were recorded after the medication administration had begun, indicating a lack of adherence to the physician's order. Additionally, LN 10 did not fully dissolve the medications in water, resulting in incomplete administration, and inaccurately documented the administration of Lactobacillus, which was not given. The Director of Nursing (DON) and the Director of Staff Development (DSD) acknowledged that LN 10's medication administration was not competently done. The DON confirmed that the medication cart should have been locked and that medications should not have been left unattended. The DSD noted that LN 10 should have contacted the physician after the error with the unlabeled medication cups. LN 10 admitted to not recalling any training or competency evaluation related to administering medications via a g-tube, highlighting a gap in the facility's competency evaluation process.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed rate of 8.33 percent. During the medication administration process, three errors were noted out of 36 opportunities. Specifically, LN 10 was observed administering medications to two residents, where errors were made in the dosage and administration of medications. For Resident 43, LN 10 dispensed medications into unlabeled cups and attempted to dissolve crushed tablets in cold water, which did not fully dissolve, resulting in a significant portion of the medication being discarded. LN 10 acknowledged that nearly a full dose of Vitamin D remained in the cup, indicating a failure to administer the complete prescribed dose. Additionally, LN 10 administered an incorrect dosage of Lactulose to Resident 43, providing 25 ml instead of the prescribed 30 ml. For Resident 10, LN 10 used a facility supply of Calcium with Vitamin D that contained 200 IU more than the physician's order. These actions were contrary to the physician's orders, as confirmed by LN 10 during an interview. The Director of Nursing stated that it was expected for medications to be administered as prescribed, highlighting a deviation from the facility's policy on administering medications safely and timely.
Inappropriate Dietary Consistency for Resident
Penalty
Summary
The facility failed to provide Resident 122 with food and drink that were palatable, appetizing, and appropriate for her dietary needs. Despite the resident's admission record indicating a mechanical soft-ground texture diet with thin liquids, she was served pureed food items and nectar thick beverages without a physician's order or clear indication. This inconsistency led to the resident expressing dissatisfaction with the meals, describing them as resembling cat food and bland, and resulted in her altering the consistency of her drinks by adding water from her bedside pitcher. Observations and interviews revealed that the resident had no diagnosis of dysphagia or swallowing issues, and the registered dietitian and speech therapist confirmed that the resident should have been on a mechanical soft diet. The facility's policy did not provide guidance on food palatability, texture, or beverage consistency, contributing to the oversight. The director of nursing acknowledged the error, stating that the resident's diet texture and fluid consistency should have been clearly understood and adhered to.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for one of its residents, identified as Resident 43. During an observation of medication administration, LN 10 was seen dispensing medications into individual, unlabeled cups and administering them through the resident's g-tube. The medications included Amlodipine, Apixaban, Lactulose, Keppra, Polyethylene glycol, Multivitamins, and Vitamin D. However, the administration of a Lactobacillus capsule, which was ordered by the physician, was not observed. Despite this, the medication administration record (MAR) inaccurately indicated that the Lactobacillus capsule had been given. Upon review, it was confirmed that LN 10 did not administer the Lactobacillus capsule and had erroneously documented it as administered. LN 10 acknowledged the mistake, noting that there had been a discussion about discontinuing the Lactobacillus order, but the order was still active at the time of administration. The Director of Nursing stated that it was expected for the clinical record to accurately reflect the care and treatment provided, which was not the case in this instance.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for one resident, identified as Resident 43. The resident, who had a g-tube for medication administration and feeding, was at risk of infection due to the actions of LN 10. During a medication administration observation, LN 10 attempted to administer a medication that had been disposed of in the trash can. Initially, LN 10 prepared the medication by dissolving crushed tablets in cold water, which did not fully dissolve, leaving a significant amount of medication in the cup. After discarding the cup in the trash, LN 10 retrieved it and considered administering the remaining medication to the resident. The incident was observed by a surveyor who intervened, preventing LN 10 from administering the medication from the trash. LN 10 acknowledged the infection control concern and decided to obtain a new dose of medication. Interviews with the DON and the IPN confirmed that the practice of administering medication from the trash can was unacceptable and not in line with infection control standards. The facility's policy on administering medications emphasized the importance of safe and timely administration, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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Illustrative
What surveyors actually found near you
We read the 493 citations issued within 25 miles in the last 12 months — including the 3 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lemon Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amaya Springs Health Care Center | 0.8 mi | ★★★★★ | 9 | 0 |
| Bella Vista Health Center | 1.1 mi | ★★★★★ | 11 | 0 |
| La Mesa Healthcare Center | 1.2 mi | ★★★★★ | 3 | 0 |
| Brighton Place Spring Valley | 1.2 mi | ★★★★★ | 2 | 0 |
| Community Care Center | 1.6 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.