Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mainplace Post Acute during CMS and state inspections, most recent first.
A resident’s medical record contained a physician progress note that included detailed summaries and plans of care for two other residents, and the DON acknowledged that such information should not appear in this resident’s chart and that physician notes were not routinely reviewed unless new orders were present. Additionally, CNA shower sheets documented repeated redness in the resident’s groin/inner thigh and lower back areas, with LVNs indicating assessments were completed, but the treatment nurse and DON confirmed there were no corresponding nursing assessments, progress notes, or change-in-condition documentation in the record, despite facility policy requiring such documentation.
A resident with a high fall risk and osteoporosis fell during a sit-to-stand lift transfer when the sling’s waist belt was not applied and staff did not properly support the resident, resulting in a hip fracture, hospitalization, and surgery. A second resident had a physician’s order for a floor mattress at bedside for safety, but the mattress was observed leaned against the wall instead of placed next to the bed.
CNA competency for a sit-to-stand lift was not established, and a resident fell during a transfer from a shower chair to a wheelchair. The resident sustained a left hip fracture requiring hospitalization and surgery. Interviews showed conflicting accounts about whether the sling’s waist belt was applied and whether the resident was supported during the transfer, and the CNA could not clearly distinguish between a personal belt, gait belt, and the sling’s waist belt.
A resident with ESRD and hemodialysis had a fluid restriction and access-site monitoring orders, but staff documented fluid intake inconsistently and inaccurately, with bedside drinks not reliably counted and intake totals not matching across records. Two residents had Permacath assessments charted as bruit and thrill present despite inaccurate documentation, and another resident’s dialysis access site was inconsistently recorded, including a wrong access location in the dialysis communication record.
A 12% medication error rate was identified during med pass observations. One LVN almost administered an outdated zinc sulfate capsule, and two other residents missed ordered doses of apixaban and dorzolamide ophthalmic solution because the meds were not available; the nurses stated they called the pharmacy for refills but did not document the calls.
Kitchen Sanitation and Food Storage Deficiencies: The facility failed to keep multiple food-contact surfaces and kitchen items sanitary. A Dietary Manager observed chipped, cracked, melted, and frayed utensils; dirty knives, spatulas, a potato masher, and tongs with crusted residue and watermarks; dirty microwaves; a hood over the stove with black dirt residue; and an ice machine with yellow and black dirt residue. A food portioning scoop was stored wet in a drawer, and a pitcher of cranberry juice was found past its use-by date.
Infection control surveillance was not carried out as written because the IP only reviewed residents when antimicrobials were prescribed and did not determine whether residents with signs and symptoms of infection but no antimicrobial orders met McGeer’s Criteria. In addition, staff did not follow infection control practices during care: an LPN gave eye drops without washing hands after oral meds, another LPN attached a needle to an insulin pen without disinfecting the pen tip, wound treatment supplies were prepared beside a resident’s water pitcher and open tissues, and a resident continued using straws that were touching the wheelchair wheel.
The facility failed to thoroughly investigate grievances for two residents. One resident’s concern involved the facility’s inventory process, and another resident’s grievance involved being transported to the wrong appointment location and waiting for three hours to return. Although resolutions were documented, there was no documentation showing how either grievance was evaluated or investigated, and the SSD and Administrator could not provide the missing investigation details.
Incomplete advance directive and POLST documentation: The facility failed to maintain a copy of one resident’s advance directive in the medical record and left key sections of two residents’ POLST forms incomplete. One resident’s record showed an executed advance directive was to be included, but it was not present, and two other residents’ POLSTs were missing required nutrition and physician signature information. RN staff verified the forms were incomplete.
Failure to Maintain Clean and Homelike Resident Rooms: The facility failed to maintain a clean, sanitary, and homelike environment in five resident rooms. Observations found missing or broken window blinds/slats in Rooms A, B, C, and D, a leaking restroom faucet in Room D, and peeling paint plus a loose restroom baseboard in Room E. The Maintenance Director verified the issues were not documented in the maintenance log, and CNAs stated several of the concerns were not reported or noticed.
The facility failed to ensure psychotropic meds were used appropriately for two residents. One resident received trazodone for sleep-related depression without documented nonpharmacological interventions being tried first, despite the care plan calling for them. Another resident received Risperdal for psychosis, but the record did not show monitoring for orthostatic hypotension even though side effects monitoring was ordered. Interviews with an LVN, RN, and Unit Manager confirmed the missing documentation and monitoring.
Failure to report verbal abuse allegations involving CNA 4: two residents stated during a resident council meeting that the CNA was rude and cursed at them, but the allegations were not reported to the Administrator or to the CDPH, L&C Program, Ombudsman Office, or local law enforcement as required. Interviews confirmed the Ombudsman was present, the Activity Director was taking notes, and the DON later acknowledged the allegations should have been reported.
Failure to Investigate Verbal Abuse Allegations: The facility did not investigate allegations that an CNA was rude and cursed at two residents after the concerns were raised during a resident council meeting. One resident was cognitively intact per MDS, while the other had mixed cognitive findings in the record. The DON and Administrator stated they were not aware of the allegations at the time, and the DON later acknowledged the allegations should have been investigated.
A resident with a fluid restriction and dialysis order had repeated dietary fluid intakes above the ordered limit, yet the care plan did not address the resident's non-compliance. Another resident with a care plan for potential pressure ulcer development had an APP mattress intervention listed for skin integrity maintenance, but staff observed the resident in bed without the mattress and RN verified the intervention had not been implemented.
The facility failed to prevent pressure injuries for two residents. One resident with severe immobility and dependence for turning developed worsening sacrococcygeal skin breakdown, and records showed multiple shifts when he was not turned or repositioned despite care plan interventions. Another resident had a physician order for an APP mattress for skin maintenance/prevention, but staff observed the resident in bed without the mattress and verified the order was not carried out; that resident also had an unstageable pressure injury and impaired mobility from a CVA.
A resident with dysphagia and a GT had enteral feeding and water flush orders that were not followed as written. The feeding system was observed with the water bag dated from the prior day, the tubing was not dated, and an LVN verified the water flush was running at 35 ml/hr instead of the ordered 40 ml/hr.
The facility failed to provide proper respiratory care for four residents. One resident received O2 without a current physician order, two residents had nebulizer equipment that was undated or not stored in labeled set-up bags, and one resident had nasal cannula tubing and a set-up bag that were not properly dated, with a nebulizer machine present despite no order for its use. Facility policy required respiratory equipment to be dated, labeled, stored properly, and changed at set intervals.
A resident with orders for pain assessment every shift and ordered non-pharmacological interventions received hydromorphone for severe pain on multiple occasions, but the MAR did not show that interventions such as repositioning, relaxation, distraction, music, massage, or a quiet environment were attempted before several doses. An LVN confirmed that non-pharmacological measures should be tried before pain medication, and the DON acknowledged the findings.
Pharmacy consultant recommendation not followed for a resident receiving finasteride. The consultant noted special handling precautions for the medication, including glove use and a face mask if crushing was required, but the warning was not added to the physician order or reflected in the medical record. The UM and DON acknowledged the omission and stated the instruction should have been added to the order.
A resident with glaucoma did not receive ordered Dorzolamide ophthalmic solution doses because the medication was unavailable in the cart, and an LPN could not document the reported pharmacy refill call. The MAR showed doses as given even though another LPN later confirmed the eye drops were not available and the 0900 dose was not administered, while the DON acknowledged missed doses could increase eye pressure and cause pain.
Improper storage and labeling of insulin and wound dressing supplies were found in two carts. An inspection of one med cart found an expired insulin pen that had not been discarded, another insulin pen without an opened date, and an opened Novolog pen missing the resident’s name and opened date; an inspection of a treatment cart found a partially used sterile bordered gauze dressing. An LVN verified the findings, and the DON was informed.
Unlabeled and undated food brought in by family was found in a resident’s room, including opened jam, bread, ham, and prune juice left on the bedside table. The facility’s policy required outside food to be labeled with the resident’s name, room number, and date, and staff confirmed the items were not properly labeled or dated. The resident had conflicting cognitive information in the record, with an H&P noting no decision-making capacity and an MDS showing a BIMS score of 14.
A facility failed to ensure one of four outside garbage dumpsters was properly closed. Surveyors observed the dumpster lid partially propped open by garbage bags and boxes, preventing it from fully closing. The Maintenance Director verified the finding and stated the lid should be fully closed at all times to prevent pests from getting in and out of the trash and for infection control purposes.
A resident with fluctuating decision-making capacity was ordered Lorazepam 0.5 mg q12h for anxiety, but the psychotropic medication consent form lacked the physician’s signature and date in the prescriber section. The MAR showed the medication was being given twice daily, and RN confirmed the consent should have been signed to inform the family about the medication’s purpose and side effects and to address questions from the spouse.
Failure to Inform Resident of State Survey Agency Contact Information: A resident with intact cognition and decision-making capacity was not informed how to contact the State Survey Agency or communicate with them during a resident council meeting. When asked, the resident stated they did not know how, and the Activity Director could not explain the process. The Administrator said the information was on the internet and in the admission packet, but the admission Coordinator could not produce documentation showing the resident had been informed.
A resident who was cognitively intact repeatedly refused showers, but staff did not document these refusals in progress notes or develop a care plan as required by facility policy. Nursing staff and medical record personnel failed to follow up on missing shower documentation, resulting in the absence of an individualized plan to address the resident's needs and preferences.
A resident with a new rash on both hands did not receive a documented change of condition assessment or required monitoring, despite a physician's order for antifungal treatment. Nursing staff confirmed that the necessary assessment, documentation, and care plan updates were not completed according to facility policy.
A resident with severe cognitive impairment and recent pituitary surgery did not receive a prescribed hydrocortisone taper because the medication order was not transcribed from hospital discharge paperwork into the facility's electronic record. The required double-check by nursing staff was not documented, resulting in the resident missing scheduled doses of the steroid.
A resident's right to manage their financial affairs was violated when the facility deposited their social security checks into the RFMS account without consent. Despite being cognitively intact, the resident was not informed or involved in the decision-making process, leading to a loss of control over their funds. The Business Office Director confirmed the lack of a formal agreement and communication, and the DON verified these findings.
A resident's medical record was incomplete and inaccurately documented, missing critical information such as lung sounds, blood pressure follow-up actions, meal intake percentages, and monitoring for urinary tract infection and diuretic side effects. These documentation gaps were confirmed by the RN Unit Manager during a review.
The facility failed to provide appropriate respiratory care for five residents, including improper maintenance of a CPAP machine, incorrect oxygen administration rates, and unsanitary storage of respiratory equipment. These deficiencies highlight a lack of adherence to physician orders and infection control protocols, potentially affecting residents' respiratory health.
The facility failed to ensure residents were free from unnecessary psychotropic medications. One resident's PRN antipsychotic order exceeded 14 days without proper evaluation, while another did not receive non-pharmacological interventions before medication administration. A third resident's records lacked documentation of required interventions, and another resident did not have informed consent or proper monitoring for medications. These deficiencies were confirmed by facility staff.
The facility failed to serve food at appropriate temperatures, affecting its palatability and nutritional value. During a tour, residents reported that hot foods were not served hot. A trayline observation showed that the plate warmer was overfilled, preventing proper heating. A test tray confirmed that several hot food items were below the required temperature. The DSS acknowledged that the current methods were insufficient to maintain hot food temperatures.
The facility failed to meet sanitary requirements in the kitchen, with issues such as improper labeling of food, utensils in disrepair, and inadequate air-drying of equipment. Observations included unlabeled turkey meat, utensils with melted handles, and wet equipment stored improperly. These deficiencies were confirmed by the DSS and acknowledged by the DON and RD.
The facility failed to inform physicians when residents were prescribed antibiotics without meeting McGeer's Criteria for a true infection, affecting several residents. This oversight was contrary to the facility's Antibiotic Stewardship Program, which aims to ensure appropriate antibiotic use. The Infection Preventionist did not document notifications to physicians, and the Director of Nursing acknowledged these findings.
Two residents were found self-administering medications without proper assessment or physician's orders. Resident 98 had topical medications at the bedside, while Resident 11 had eye drops. The facility failed to document care plans or conduct assessments for their ability to self-administer, contrary to policy. Staff interviews confirmed the lack of necessary procedures, posing a risk of inappropriate medication use.
A resident experienced a change in condition with symptoms of vomiting, abdominal discomfort, and refusal to eat. The facility failed to promptly notify the physician and conduct a thorough assessment, leading to a deficiency. Initial vital signs were taken, but no further monitoring or reassessment was documented. The resident's condition worsened, and they were found unresponsive and expired. Interviews with staff revealed awareness of the situation but a lack of timely action.
A resident with pressure injuries did not receive a physician-ordered low air loss mattress, and weekly assessments of the injuries were not conducted as per facility policy. Staff interviews confirmed lapses in communication and documentation, contributing to the deficiency in care.
A resident with a history of falls and assessed as high risk did not have floor mats placed on both sides of their bed as ordered by the physician and outlined in their care plan. This oversight was confirmed by RN 3 and acknowledged by the DON, indicating a failure to adhere to the facility's fall management policy.
The facility failed to manage pain appropriately for two residents. One resident received acetaminophen for pain levels that required tramadol, without informing the physician. Another resident did not receive non-pharmacological interventions before narcotic medication as ordered. Staff interviews confirmed these deficiencies.
A Pharmacy Consultant failed to identify an irregularity in a diabetic resident's medication regimen review, as the resident did not have an HbA1C test for 10 months despite being on insulin. The facility's policy required monthly reviews to identify irregularities, but no recommendations were made regarding the HbA1C test. The DON acknowledged the oversight and the potential complications from not monitoring HbA1C levels.
A facility failed to ensure proper medication storage and labeling, as medications were found at a resident's bedside without a physician's order or care plan. Additionally, an expired culture swab was discovered in a treatment cart, which had not been removed during a previous check. Staff interviews confirmed these deficiencies.
A facility failed to maintain safe infection control practices when an LVN used inappropriate wipes to clean a wrist blood pressure monitoring device with a Velcro cuff. The wipes were intended for hard, non-porous surfaces, not suitable for the cuff. The LVN confirmed the misuse and acknowledged the potential for spreading germs and bacteria.
A resident did not receive the pneumococcal vaccine despite consent being obtained, as the facility's IP failed to administer it within the expected timeframe due to being busy during influenza season. The DON acknowledged the oversight.
A resident's room was found to be in disrepair, with scratches and chipped paint on the wall adjacent to the bed. The resident expressed a desire for a neat and clean environment, as she spent a lot of time in her room. The DON was informed and verified the findings.
A resident's care plan for continuous oxygen therapy was not followed, as the resident received oxygen at four liters per minute instead of the prescribed two liters per minute. This discrepancy was confirmed during an observation and interview with an LVN, highlighting a failure to adhere to the care plan and physician's order.
The facility failed to properly store garbage in one of its dumpsters, as the right-side lid was missing, exposing the contents. The Maintenance Director confirmed the lid had been broken since August 2024 and was awaiting repair or replacement by the garbage company. Despite this, the dumpster was still in use, and the issue was acknowledged by the RD, DSS, and DON.
The facility did not provide adequate communal dining space for residents who do not require staff assistance with meals. During a resident council meeting, several residents expressed that only those needing assistance could access the communal dining area, limiting their socialization opportunities. The administrator acknowledged the issue and mentioned plans to address it.
A facility failed to develop comprehensive care plans for two residents, omitting a problem statement for breast cancer treatment with Femara and lacking measurable timeframes for mobility goals. This posed a risk of inconsistent care, as confirmed by the DON.
A resident was not informed or given the right to choose when the facility changed his weekly outpatient psychiatric services to monthly in-house services. The resident, who was cognitively intact and capable of making decisions, expressed that he did not agree with the change and would have preferred to continue with his outpatient services. The facility's failure to communicate and obtain consent was confirmed by staff interviews and acknowledged by the DON.
Inaccurate Physician Note and Missing Skin Assessment Documentation
Penalty
Summary
The deficiency involves failures in maintaining accurate and complete medical records for a resident in accordance with facility policy and accepted professional standards. The facility’s policy on nursing clinical documentation requires that the clinical record be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition. For one resident, admitted on a specified date and documented as having capacity to make medical decisions, review of the physician’s progress note dated 3/16/26 at 0427 hours showed that, in addition to a detailed summary and plan of care for this resident, the same note also contained detailed summaries and plans of care for two other residents. During an interview and concurrent record review, the DON stated that physician progress notes were not reviewed after entry unless there was a new order to review and verified that the medical information for the other residents should not have been listed in this resident’s medical record. The facility’s policy on change in condition requires nurses to perform and document an assessment of the resident, identify the need for additional interventions, and communicate with the provider as needed. Review of the resident’s CNA Skin Observation (shower sheets) showed multiple entries documenting redness in the groin/inner thigh and lower back areas on three separate dates, with LVNs indicating that assessments were done. However, the treatment nurse confirmed there were no corresponding assessments, progress notes, or change-in-condition documentation in the medical record related to these findings. In a subsequent interview, the DON also verified that there were no such assessments or progress notes corresponding to the shower sheet findings and further verified that nurses should be documenting their skin assessments.
Unsafe Transfer and Missed Fall Precaution
Penalty
Summary
The facility failed to keep two sampled residents free from accident hazards. One resident, who had diagnoses including a left femur fracture history, osteoporosis, generalized muscle weakness, and a high fall risk score, sustained a fall while being transferred from a shower chair to a wheelchair with a sit-to-stand lift. The resident reported that she fell during the transfer, and facility documentation showed she landed on the floor, had severe hip and leg pain, and was later found to have an impacted left subcapital femoral neck fracture requiring hospitalization and surgery. Statements and interviews about the lift transfer were inconsistent, but multiple sources indicated the resident was not properly secured during the transfer. A CNA stated the resident let go of the handlebars and slipped from the sling, while another CNA stated the resident was not wearing the sling’s waist belt and that no one was holding or supporting her while she was elevated. The resident also stated she was not wearing the sling’s waist belt. The facility’s own lift instructions required proper sling placement, secure waist-belt use, and two-person assistance, yet the investigation did not establish all of the circumstances surrounding the fall. The DON stated she was not aware the waist belt was not applied and acknowledged that both CNAs should have been asked whether either was holding or supporting the resident during the transfer. A second resident had a physician’s order for a floor mattress at bedside for safety, but observation showed the floor mattress was leaned against the wall and not placed next to the bed. LVN 2 verified the mattress was not in place and stated floor mattresses were used for safety and fall precautions and should be in place. The resident’s record showed cognitive impairment and impaired upper and lower extremity function on one side, and the physician’s order for the floor mattress remained in the record while the mattress was not positioned as ordered.
CNA Lacked Competency for Sit-to-Stand Lift Transfer
Penalty
Summary
The facility failed to ensure that one CNA demonstrated the competencies and skill sets needed to provide safe nursing care when using a sit-to-stand lift. CNA 7 was not shown to be competent in operating the lift, and the record review showed her skills checklist did not document competency for use of a hydraulic lift or for accident prevention and safety measures. The facility also did not have an in-service for the sit-to-stand lift before the incident; the only documented training covered manual transfers with a gait belt and use of a Hoyer lift, not the sit-to-stand lift. Resident 4 was admitted to the facility and later returned after hospitalization for a left hip fracture. On 10/18/25, Resident 4 was being transferred from a shower chair to a wheelchair using a sit-to-stand lift when she fell to the floor. Nursing notes documented that she was found seated on the floor and leaning against the bathroom door, crying, and reporting severe hip and bilateral leg pain. She was sent to an acute care hospital for further evaluation and later had a left hip fracture requiring surgery. Resident 4 also reported symptoms of depression following the incident. Interviews showed conflicting accounts of how the transfer was performed and whether the resident was properly secured. CNA 6 stated Resident 4 slipped down during the transfer and that neither CNA was holding or supporting her while she was elevated in the sling. CNA 7 initially stated the resident was not wearing the sling’s waist belt and said the fall could have been prevented if the resident had been properly strapped, but later changed her statement and said she meant the resident was not wearing a personal belt. During a later demonstration, CNA 7 was able to apply the sling and perform the transfer with the COTA and DON present, but she remained uncertain about which sling had been used for Resident 4 and could not clearly differentiate between the personal belt, gait belt, and the sling’s waist belt. The COTA stated that a properly secured resident would not fall if they let go of the handlebars, and the DON stated Resident 4 should have been held or supported during the transfer.
Inaccurate Dialysis Fluid and Access Monitoring
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for residents who required dialysis. For Resident 63, who had ESRD and was receiving hemodialysis through a right chest Permacath, the physician ordered a 1200 ml per day fluid restriction with specific amounts assigned to nursing and dietary. The resident was observed with bottled drinks at the bedside, and the record showed the dietary fluid intake exceeded the prescribed amount on multiple days. The Intake and Output Record also showed different totals that did not match the dietary fluid intake record, and staff interviews confirmed that CNAs and nurses were documenting fluid intake separately and not consistently including all fluids consumed by the resident. Resident 63’s dialysis access was also not accurately assessed in the record. The Facility/Dialysis Center Nursing Communication Record documented bruit and thrill as present on multiple dates, and staff later acknowledged that the Permacath assessment had been documented inaccurately. During interviews, a CNA stated the resident had bottled water and soda at the bedside and that she did not include those drinks in the intake record because she did not see the resident take a sip and did not ask him whether he drank them. A unit manager confirmed the resident had a fluid intake greater than the prescribed dietary amount and that the daily intake monitoring was inaccurate and inconsistent. For Resident 1, who also had ESRD and dialysis treatment, the physician ordered a 1000 ml per day fluid restriction and daily monitoring of the right upper chest Permacath site. The resident was observed with a non-graduated pitcher of water at bedside and drinking a bottled coffee drink. A CNA stated she was not aware of the fluid restriction and had not been told about precautions. The dietary fluid intake record showed repeated totals above the prescribed dietary allowance, while the Intake and Output Record showed lower and inconsistent totals. The record also showed the Permacath was documented as having bruit and thrill present, and the unit manager verified the inaccurate documentation. Resident 135, who had ESRD and hemodialysis, had an order to monitor the right upper chest Permacath every shift for signs and symptoms of infection, swelling, and bleeding. The dialysis communication records showed inconsistent and inaccurate documentation of the access site, including entries that listed the wrong access location as the left upper arm when the resident’s access was a right upper chest Permacath. The record also showed some dialysis communication forms left the pre-dialysis access site blank or documented only bruit and thrill assessments. RN staff acknowledged that the access was not properly documented and assessed in the medical record.
Medication Administration Errors and Missed Doses
Penalty
Summary
A medication error rate of 12% was identified after three medication errors occurred out of 25 opportunities during medication administration for one sampled resident and two nonsampled residents. Facility policy required medications to be administered according to prescriber orders and for the expiration or beyond-use date on the medication label to be checked before administration. During observation, an LVN preparing medications for one resident almost administered an outdated zinc sulfate capsule after initially checking the medications and then rechecking the container when questioned. For another resident with an order for apixaban 5 mg every 12 hours for paroxysmal atrial fibrillation, the 0900 dose was not administered because the medication was not available, and the LVN stated she called the pharmacy for refill but did not document it. For a third resident with an order for dorzolamide hydrochloride ophthalmic solution 2% twice daily for glaucoma, the medication was also not administered because it was not available, and the LVN stated she called the pharmacy for refill but was unable to provide documentation of the call.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and related food service equipment. During an initial kitchen tour with the Dietary Manager, three rubber spatulas with red handles were observed chipped and cracked at the edges, one stainless steel spatula with a white handle was discolored and partially melted, and one white basting brush had frayed and worn-out bristles. The Dietary Manager acknowledged that old and worn-out kitchen utensils should have been discarded. Additional observations showed multiple kitchenware items were not clean to sight and touch. Seven cutting knives with white handles had dry, crusted residue on the blades, cloudy film, and watermarks. One stainless steel spatula with a white handle was dirty and had watermarks, one stainless steel potato masher with a black handle had dry, crusted food residue, and three stainless steel tongs had dry, crusted residue and watermarks. The Dietary Manager stated the dirty and crusted kitchenware should have been washed for infection control purposes. The kitchen microwaves were also observed dirty, with dry food residue in the microwave doors and inside both units, including the microwave on the countertop shelf and the microwave in the utility room. The hood over the stove had black dirt residue, and the Dietary Manager stated the residue should not have been present. The ice machine in the utility room had yellow and black dirt residue on the internal panel adjacent to the water curtain above and lateral to the ice bin. In addition, one stainless steel scoop used for food portioning was stored wet in a metal drawer with traces of water inside the drawer and on the scoop, and one pitcher of cranberry juice was stored in the refrigerator with a prep date of 3/1/26 and a use-by date of 3/3/26, indicating it was expired when observed.
Infection Control Program Not Followed During Surveillance and Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program in accordance with its own policies and procedures. The infection preventionist stated that resident infection surveillance was performed only when a resident was prescribed an antimicrobial medication, and the facility did not determine whether residents who had signs and symptoms of infection but were not prescribed antimicrobials met McGeer’s Criteria. Review of the monthly infection surveillance logs from January 2025 through February 2026 showed counts for HAIs, CAIs, and residents who did not meet McGeer’s Criteria, but the documentation reviewed showed that all residents in those categories had been prescribed antimicrobial medications. There was no documentation showing whether residents with signs and/or symptoms of infection who were not prescribed antimicrobial medications met McGeer’s Criteria. The facility also failed to follow infection control practices during medication administration. During observation of medication administration for one resident, an LVN administered several pills and then gave cyclosporine ophthalmic emulsion using the same gloves without washing hands with soap and water before the eye solution. The facility’s eye drop administration policy required hand washing with soap and water prior to administration of eye drops. The LVN stated she should have sanitized her hands again before administering the eye drops and acknowledged that failure to clean hands before the eye solution could lead to eye infection. In another medication observation, an LVN prepared Novolog insulin pen medication for a resident and attached a new needle without sanitizing the pen tip with alcohol first. The facility’s insulin injection policy required swabbing the rubber cap with an alcohol wipe before preparation. The LVN later stated she should have wiped the insulin pen with alcohol prior to attaching the new needle and confirmed she did not do so. During a wound treatment observation for another resident with a sacrococcyx pressure injury, an LVN kept the resident’s water pitcher and an open box of tissues together with the wound treatment supplies at the bedside. In a separate observation, a resident was seen using two connected straws tied to the wheelchair hand grip while the straws were touching the wheelchair wheel, and the LVN did not provide new straws or water. An RN stated staff should have provided new straws because the original straws were touching the wheel and should have provided education.
Grievances Not Thoroughly Investigated
Penalty
Summary
The facility failed to ensure grievances were thoroughly investigated for two residents. For Resident 54, the grievance involved a concern about the facility’s inventory process. The grievance log showed the concern was received and a resolution was documented, but there was no documentation showing how the grievance was evaluated or investigated. During interview, the Social Services Director stated the concern had been brought up during a Resident Council meeting and that Resident 54 did not have concerns when asked, but she could not provide documentation showing what initiated the grievance or how it was investigated. For Resident 165, the grievance was filed by the resident’s son after the resident was transported to the wrong appointment location and waited for three hours before returning to the facility. The grievance log showed the complaint was received and a resolution was documented, but there was no documentation showing how the grievance was evaluated or investigated. The Social Services Director could not provide documentation showing whether the facility attempted to determine where the transportation error started, who was involved in the process, or how the error occurred. The Administrator verified the grievance forms were missing the investigation element, and the DON was informed and acknowledged the findings.
Incomplete advance directive and POLST documentation
Penalty
Summary
The facility failed to ensure a copy of an advance directive was obtained and maintained in the medical record for one resident, and failed to ensure the POLST forms for two residents were completely filled out. Review of facility policies showed the clinical record was required to be a concise and accurate account of the resident’s care and that, if a resident had an advance directive, a copy was to be included in the medical record. Resident 5’s record showed an advance directive had been executed and that a copy would be included in the record, and the resident’s H&P noted the resident had the capacity to understand and make decisions, but the medical record did not contain a copy of the advance directive. The SSD verified the document was not in the record. Resident 130’s POLST had Section C for artificially administered nutrition left blank, and Section D for information and signatures was incomplete, with the physician’s name, phone number, license number, signature, and date left blank. Resident 135’s POLST also had Section D for information and signatures left blank and undated. RN staff verified both POLST forms were incomplete and stated the forms should have been completed and signed by the physician to verify the residents’ wishes and code status.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment in five resident rooms. Room A had four missing vertical blinds. Room B had two broken blind slats. Room C had one broken blind slat. Room D had one missing blind slat and a leaking restroom faucet sink. Room E had peeling wall paint below the overhead light and a restroom baseboard behind the toilet and below the sink that was coming off. The facility policy titled Physical Environment, Environmental Conditions/Homelike Environment, revised 11/2019, states the facility must provide a safe, functional, sanitary, and comfortable environment through monthly environmental rounds. During the tour, these room conditions were observed and later reviewed with the Maintenance Director, who could not find documentation that the findings had been reported in the maintenance log for the past two months. CNA 2 stated the issues in Rooms A, B, C, and D were not reported or had not been documented, and CNA 3 stated the issues in Room E were not noticed and not reported. The Maintenance Director verified the findings were not on the maintenance log, and the DON acknowledged the findings.
Unnecessary Psychotropic Medication Use and Incomplete Monitoring
Penalty
Summary
The facility failed to ensure two sampled residents were free from unnecessary psychotropic medication use. For Resident 4, the record showed a physician’s order for trazodone HCl 50 mg, two tablets at bedtime for depression manifested by difficulty sleeping at night. The facility’s psychotropic medication policy stated psychotropic medications should be given only after nonpharmacological interventions had been attempted and failed, and Resident 4’s care plan included nonpharmacological interventions for trazodone use. However, the medical record did not show documented evidence that nonpharmacological interventions were attempted before trazodone was administered, and the MAR for February and early March 2026 did not show documentation of those interventions before 3/9/26. Resident 4’s H&P stated the resident had the capacity to make decisions. During interviews and concurrent record review, LVN 9 and RN 1 verified that nonpharmacological interventions should have been provided before trazodone administration and confirmed there was no documented evidence that this occurred prior to 3/9/26. The DON was informed of and acknowledged these findings. For Resident 163, the record showed orders for Risperdal 1 mg for dementia with psychosis manifested by sudden anger outburst, later changed to psychosis manifested by sudden anger outburst, along with orders to monitor for common, less common, and rare antipsychotic side effects every shift, including orthostatic hypotension. The resident received risperidone on multiple dates in February and March 2026, but the medical record did not show monitoring for orthostatic hypotension. The Unit Manager stated residents on antipsychotic medications were monitored for orthostatic blood pressure and that this was done weekly on Sundays, and verified that Resident 163 was not monitored for orthostatic hypotension while on risperidone. The DON was informed of and acknowledged these findings.
Failure to Report Verbal Abuse Allegations
Penalty
Summary
The facility failed to implement its policy for reporting a reasonable suspicion of a crime under section 1150B of the Act when it did not report allegations of verbal abuse involving CNA 4 to the CDPH, L&C Program, Ombudsman Office, and local law enforcement. The allegations were raised during a resident council meeting and involved two residents, Resident 54 and Resident 154, who both stated that CNA 4 was rude and cursed at them. The report states that the facility did not document that the allegations were reported to the Administrator, and the DON later acknowledged that the Activity Director should have reported the allegations to the Administrator and the appropriate agencies. Resident 54’s record showed a history of no capacity to understand and make decisions on the H&P, while the MDS showed a BIMS score of 14 and described the resident as cognitively intact. Resident 154’s H&P showed capacity to understand and make decisions, and the MDS showed a BIMS score of 15 and described the resident as cognitively intact. During interviews, the Ombudsman stated she was present at the resident council meeting and aware of the allegations, and the Activity Director was present and taking notes, but the Activity Director could not produce documentation that the allegations had been reported to the Administrator. The DON and Administrator stated they were not aware of the allegations from the resident council meeting.
Failure to Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of verbal abuse involving CNA 4 for two residents, identified in the report as Residents 54 and 154. The facility’s Abuse: Prevention of and Prohibition Against policy stated that all allegations of abuse, neglect, misappropriation of resident property, and exploitation would be promptly and thoroughly investigated by the Administrator or designee, but the allegations reported during the resident council meeting were not investigated at the time they were raised. Resident 54’s record showed conflicting cognitive information, with an H&P noting no capacity to understand and make decisions and an MDS showing a BIMS score of 14. Resident 154’s record showed capacity to understand and make decisions, with an MDS BIMS score of 15. During the resident council meeting with the Ombudsman, Resident 154 stated CNA 4 was rude and cursed at her, and also stated CNA 4 was rude and cursed at Resident 54. Resident 154 said the allegation had been reported at the prior month’s resident council meeting. When interviewed, the DON and Administrator stated they were not aware of the allegations from that meeting, and the Administrator stated staff must report abuse allegations to the Administrator and conduct an investigation. The DON later acknowledged that the allegations reported during the resident council meeting should have been investigated.
Care Plan Not Developed for Fluid Restriction and APP Mattress Not Implemented
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 1's non-compliance with a prescribed fluid restriction. Resident 1 had a physician's order dated 2/13/26 for a 1000 ml per day fluid restriction, with specific amounts assigned to nursing and dietary staff across shifts, and a later order for dialysis every Tuesday and Saturday. Review of the fluid intake record from 2/13/26 through 3/8/26 showed multiple days when Resident 1's dietary fluid intake exceeded the prescribed 360 ml per day, including documented intakes ranging from 500 ml to 1700 ml. Review of the plan of care showed no care plan problem addressing the resident's non-compliance with fluid restrictions. During interview, the Unit Manager verified the resident was non-compliant with the fluid restriction and confirmed the care plan did not include this issue. The facility also failed to implement a care plan intervention for Resident 17, who had a care plan focus for potential pressure ulcer development related to CVA, aging process, and decreased mobility. The care plan, initiated on 2/14/26, included an APP mattress for skin integrity maintenance, initiated on 3/1/26. However, on 3/4/26, Resident 17 was observed lying in bed without an APP mattress. During a later observation and interview, RN 1 verified the resident had the care plan and that the APP mattress intervention was listed, but confirmed it had not been implemented.
Failure to Prevent Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent pressure injuries for two residents reviewed for skin integrity concerns. Facility policy stated residents without pressure ulcers were to receive appropriate preventive measures, and the cited NPIAP guideline noted that extended periods of lying or sitting without pressure redistribution could lead to a pressure injury. The report identified failures involving both repositioning and implementation of a physician-ordered pressure-relief mattress. Resident 147 was admitted with significant immobility and dependence for turning. A Braden Scale dated 8/9/25 documented that the resident was bedfast, completely immobile, and required moderate to maximum assistance with friction and shear. The resident had blanchable redness to the sacrococcyx area on admission, later developed non-blanchable redness on the sacrum, then a Stage 2 pressure injury to the sacrococcyx, and later an unstageable pressure injury with slough, necrotic tissue, and eschar. Documentation showed the resident was not turned or repositioned during multiple shifts in August and September 2025, despite care plan interventions calling for repositioning as often as possible and re-checking and re-repositioning as needed. The DON stated CNAs were expected to document turning every shift, and LVN 6 stated the resident could not turn himself and CNAs were expected to turn and reposition him. Resident 17 had a physician’s order for an APP mattress for skin maintenance/prevention, but observations on 3/4/26 showed the resident lying in bed without an APP mattress. LVN 10 and RN 1 both verified the order existed and that the facility had failed to carry it out. The resident was also documented as having an unstageable pressure injury on the left dorsum hallux and was noted by RN 1 to be at risk for pressure injuries due to left-sided weakness and impaired mobility from a CVA.
Enteral Feeding and Water Flush Not Managed per Order
Penalty
Summary
The facility failed to provide appropriate care and services for enteral feedings for Resident 147, who had dysphagia and a GT and was ordered NPO. The resident had physician’s orders for Jevity 1.5 to be administered via external feeding pump at 1200 hours at 70 ml/hr for 20 hours, and a separate order dated 3/4/26 for a continuous water flush of 40 ml/hr for 20 hours to provide 800 ml of water via the external feeding pump. On 3/5/26, the resident was observed with the Kangaroo OMNI enteral feeding pump off and not connected at one point, and later receiving the same enteral feeding formula. The formula was labeled as initiated on 3/4/26 at 1200 hours, and the water bag was also dated 3/4/26 at 1200 hours. During an observation, interview, and concurrent record review with LVN 2, the water flush rate was verified to be administering 35 ml per hour instead of the ordered 40 ml per hour, the water bag was dated from the prior day, and the enteral feeding tubing connected to the resident was not dated. The DON was informed of and acknowledged these findings.
Respiratory equipment not properly dated, stored, or ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for four sampled residents who were receiving or had orders related to oxygen or nebulizer treatment. Facility policy required oxygen cannulas or masks and disposable humidifiers to be changed at least every seven days, with tubing, masks, humidifiers, and other disposables dated in an identifiable fashion, and labeled, dated bags provided when not in use. The facility also had a policy for oxygen therapy documentation that included the ordered rate, route, rationale, frequency, and duration of treatment. One resident was observed receiving oxygen by nasal cannula even though the medical record did not show a physician’s order to administer oxygen at the time the oxygen was being used. Staff acknowledged that the order had been mistakenly discontinued by the MDS Resource. Another resident had a nebulizer mask and tubing that were observed undated, unlabeled, and not stored in a set-up bag when not in use, despite a physician’s order for ipratropium-albuterol via nebulizer as needed for shortness of breath or wheezing. A third resident’s nebulizer mask and tubing were observed without a date, while the storage bag was dated several days earlier. Staff stated the equipment should have been changed and properly labeled. A fourth resident had nasal cannula tubing dated more than a month earlier and an undated set-up bag, and a nebulizer machine was also observed by the bedside even though staff later confirmed there was no physician’s order for oxygen or for use of a nebulizer machine. The DON acknowledged the findings for all four residents.
Failure to Document Non-Pharmacological Pain Interventions Before Opioid Administration
Penalty
Summary
The facility failed to ensure appropriate pain management for Resident 4, who had the capacity to make decisions and had physician orders for pain assessment every shift and for non-pharmacological pain interventions as needed. The resident’s orders included acetaminophen for mild pain and hydromorphone HCl for mild to moderate pain and for severe pain, along with ordered non-pharmacological interventions such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage. Review of the March 2026 MAR showed Resident 4 received hydromorphone HCl 2 mg, two tablets by mouth, on multiple occasions when pain levels were documented as 7, 8, 9, or 10. However, the MAR did not show that non-pharmacological pain interventions were attempted before hydromorphone was administered on several of those occasions, including administrations at 0958 on 3/1/26, 2014 on 3/2/26, 0552 on 3/4/26, 0900 on 3/8/26, and 0615 on 3/9/26. During interview and concurrent record review, the LVN stated non-pharmacological interventions should be attempted prior to pain medication administration and verified the findings; the DON was also informed and acknowledged the findings.
Pharmacy Consultant Recommendation Not Added for Finasteride Handling
Penalty
Summary
The facility failed to ensure that the pharmacy consultant’s recommendation was acted upon for one resident reviewed for drug regimen review. The consultant pharmacist’s medication regimen review for the resident noted that women who are pregnant or may get pregnant must not handle or administer broken or crushed finasteride tablets, and advised that nurses wear gloves when handling the tablets and wear gloves and a face mask if crushing was required by adding the warning to the medication sheet. The resident had an order for finasteride 5 mg by mouth in the afternoon, but the physician’s order and the medical record did not show that the consultant pharmacist’s recommendation had been added. During observation, interview, and concurrent medical record review, the Unit Manager verified that the recommendation had not been followed and stated that the warning should have been added to the physician’s order. The Unit Manager also stated that the yellow sticker on the finasteride bubble pack was intended to alert nurses to check the physician’s order for special handling instructions. The DON stated that Unit Managers and RNs were responsible for following up pharmacy consultant recommendations within 72 hours or a week and acknowledged that the special handling recommendation for finasteride should have been added to the physician’s order.
Missed and Misdocumented Dorzolamide Eye Drops
Penalty
Summary
Resident 156 was observed during medication administration on 3/4/26, and LVN 3 prepared and administered several medications, including four pills and cyclosporine 0.05% ophthalmic emulsion. Review of the resident’s order summary showed an order dated 2/27/26 for Dorzolamide hydrochloride Ophthalmic Solution 2% to instill one drop in both eyes twice daily at 0900 and 1700 for glaucoma. The Dorzolamide ophthalmic solution was not observed being administered during the medication pass, and later LVN 3 verified it was not given because it was not available. LVN 3 stated she called the pharmacy for a refill but could not provide documentation of the call and had not documented it in the record. The resident’s medical record showed Dorzolamide eye solution documented as given on 3/4/26 at 1700 and on 3/5/26 at 0900. However, on 3/5/26 during another observation and record review, LVN 1 was unable to locate the Dorzolamide eye solution in the medication cart and confirmed it was not available. LVN 1 stated the 0900 dose on 3/5/26 was not administered, despite being documented as given, and stated missing doses would make the symptoms worse. The DON was informed and acknowledged that missed Dorzolamide doses could increase eye pressure and cause pain.
Improper Storage and Labeling of Insulin and Wound Dressing Supplies
Penalty
Summary
Proper medication storage was not maintained for two of six medication/treatment carts inspected. During review of facility policies, the facility’s insulin injection policy stated opened insulin should not be used after 28 days, the medication labeling policy required the resident’s name to be maintained directly on the actual product container when a label could not fit on the product, and the administering medication policy stated the expiration or beyond-use date must be checked before administration, the date opened must be recorded when opening a multi-dose container, and insulin pens must be clearly labeled with the resident’s name or other identifying information. On 3/4/26, an inspection of Medication Cart A with an LVN found Resident 148’s insulin Glargine pen labeled with an opened date of 1/26/26 and an expiration date of 2/23/26, but the insulin had not been discarded after 2/23/26. The same cart also contained Resident 12’s insulin Lantus pen without an opened date, and one opened Novolog insulin pen that was not labeled with the resident’s name or opened date. The LVN confirmed these findings. On 3/5/26, an inspection of Treatment Cart B with another LVN found one partially used bordered gauze sterile wound dressing in the treatment cart, and the LVN verified the finding. The DON was informed of and acknowledged these findings on 3/5/26.
Unlabeled and Undated Outside Food in Resident Room
Penalty
Summary
The facility failed to ensure food brought in from outside sources for resident consumption was properly labeled, dated, and stored for one of 30 sampled residents, Resident 108. The facility’s policy stated that food and beverages brought in should be labeled with the resident’s name, room number, and date, and that perishable items were encouraged for immediate consumption or otherwise stored in the resident’s designated refrigerator. Resident 108’s medical record showed no capacity to make decisions in the H&P, while the MDS assessment showed a BIMS score of 14, indicating the resident was cognitively intact. During the initial tour, Resident 108 was observed with an opened fruity pineapple jam on the bedside table that was unlabeled, undated, and sticky on the outside of the bottle. Later, the resident’s room contained unlabeled and undated bread in a clear bag, a bowl of ham, and a can of prune juice on the bedside table. CNA 5 stated the facility usually labels and dates food brought by family members and did not know when the jam had been brought in. Unit Manager 1 verified the outside food was unlabeled and undated, and the DSD stated food is supposed to be labeled with the resident’s name, room number, and date and checked for the correct diet when brought in by families or visitors. The DON acknowledged the findings.
Improperly Stored Garbage Dumpster
Penalty
Summary
The facility failed to ensure that garbage was properly stored in one of four outside dumpsters. During observation, one dumpster was seen with its lid partially propped open by garbage bags and boxes, which prevented the lid from fully closing. The facility's policy for miscellaneous areas, garbage, and trash required daily inspection to ensure no debris was on the ground or surrounding area and that lids were closed. The Maintenance Director was interviewed and verified the observation, stating the dumpster lid should be fully closed at all times to prevent pests from getting in and out of the trash and for infection control purposes. The DON was later informed of and acknowledged the finding.
Incomplete informed consent for psychotropic medication
Penalty
Summary
The facility failed to ensure informed consent was completed before initiating a psychotropic medication for one resident. Resident 80 had a history of fluctuating capacity to understand and make decisions, and the resident’s physician ordered Lorazepam 0.5 mg by mouth every 12 hours on 2/17/26 for anxiety manifested by verbalization of fear that someone would hurt him. The resident’s Psychotherapeutic Drug Informed Consent form for Lorazepam was dated 2/17/26, but the prescriber section did not include the physician’s signature or date. The resident’s MAR showed the Lorazepam was being administered twice daily from 3/1/26 through 3/9/26. During a concurrent interview and record review on 3/10/26, RN 3 confirmed the consent form should have been signed by the physician to inform the family of the medication’s purpose and side effects and to address any questions the spouse had, and stated informed consent should have been signed within 72 hours. The DON was informed of the findings on 3/11/26 and acknowledged them.
Failure to Inform Resident of State Survey Agency Contact Information
Penalty
Summary
The facility failed to ensure that Resident 154 was informed of how to contact the State Survey Agency and how to communicate with them when needed during the resident council meeting. Resident 154 was admitted to the facility with a history showing capacity to understand and make decisions, and the resident's H&P and MDS documented that the resident was cognitively intact with a BIMS score of 15. During a concurrent observation and interview in the dining room, residents attending the council meeting were asked about their rights in the facility and how to contact the State Survey Agency. Resident 154 stated they never know and do not know how. Facility staff later stated that resident rights were read at the beginning of the meeting, but the Activity Director could not explain how residents were informed about contacting the State Survey Agency. The Administrator said the contact information could be searched on the internet and was in the admission packet, but the admission Coordinator was unable to produce documentation showing Resident 154 had been informed, stating the admission packet could not be found.
Failure to Develop Care Plan for Resident's Refusal of Showers
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing a resident's repeated refusals to shower or bathe. Despite the facility's policy requiring the interdisciplinary team to create a person-centered care plan that includes measurable objectives and timeframes for all identified needs, there was no care plan in place for the resident's ongoing refusals. The resident, who was cognitively intact and able to make decisions, had a documented history of refusing showers on multiple occasions, as evidenced by shower sheets and staff interviews. However, these refusals were not documented in the resident's progress notes, and no care plan was initiated to address the refusals or to outline alternative interventions or education efforts. Interviews with nursing staff and review of facility records confirmed that required documentation and follow-up actions were not completed. The assigned CNAs and licensed nurses did not consistently report or document the refusals as required by facility policy, and missing shower sheets were not followed up by medical record staff or the Director of Staff Development. The lack of a care plan for the resident's refusals meant that individualized, consistent care was not ensured, and the facility's own procedures for addressing such refusals were not followed.
Failure to Assess and Monitor Change in Skin Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident who developed a rash on both hands. According to the facility's policy, any change in a resident's condition, such as a new skin issue, requires a licensed nurse to perform and document an assessment, notify the physician and responsible party, and monitor and document the resident's condition for at least three days. In this case, a physician ordered miconazole nitrate cream to be applied to the resident's hands for the rash, but there was no documented evidence that a change of condition assessment or required monitoring was completed. Interviews with nursing staff confirmed that the assessment and documentation were not performed as required by policy. The resident involved was cognitively intact and able to make decisions, as indicated by a BIMS score of 13 and a recent history and physical examination. Despite the new order for antifungal treatment, the medical record lacked documentation of assessment, monitoring, or care plan updates related to the rash. Nursing staff acknowledged the omission, and the DON confirmed awareness of the findings during the survey.
Failure to Administer Steroid Taper as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to administer hydrocortisone (Cortef) as ordered for a resident who had recently undergone pituitary tumor removal and was readmitted from an acute care hospital. The resident, who had severe cognitive impairment and lacked capacity to make medical decisions, was discharged from the hospital with specific orders for a hydrocortisone taper. These orders included a series of scheduled doses to be administered over several days, starting with a 25 mg dose, followed by 20 mg and 10 mg doses, and then a maintenance dose of 5 mg every afternoon. Upon review, it was found that the hydrocortisone taper was not transcribed from the hospital discharge paperwork into the facility's electronic medical record. The process for admitting residents required the admission nurse to review and transcribe discharge orders, which were then to be double-checked by the night shift RN supervisor. However, the hydrocortisone order was missed during this process, and there was no documentation indicating that the required double-check or recapitulation of orders had been completed by the RN supervisor. Interviews with facility staff, including the RN, unit manager, pharmacy consultant, and DON, confirmed that the hydrocortisone order was present in the hospital discharge paperwork but was not entered into the facility's system or administered as prescribed. The pharmacy consultant explained the importance of a steroid taper and the potential effects of abrupt discontinuation, but the report did not document any specific adverse outcomes for the resident. The deficiency was substantiated by the lack of documentation and failure to follow the facility's policy and procedure for medication administration.
Plan Of Correction
How corrective action will be accomplished for those residents affected by the deficient practice: The Facility was made aware of the incident. MD was notified and transcribed the missing Hydrocortisone order. MD was notified of the incident, conducted an investigation, and completed an incident report. Initiated monitoring for resident 1. Resident remains in stable condition and no negative effects were noted on resident 1. How the facility will identify other residents having the potential to have been affected by the deficient practice and corrective action taken: The Medical Records Director/Designee conducted audits on all admissions on April 4, 7, 8, 9, 2025, and ensured that orders from the Hospital are carried out promptly. The DON conducted in-service to the Licensed Nurses on 4-4-25 regarding the admission process to ensure that discharge orders from the Hospital are being carried out correctly. The Admission nurse who failed to transcribe the Hydrocortisone was given 1:1 in-service and training on the admission process on 03-20-25 and guided on verification/comparing of hospital discharge orders and ensuring that each order is double-checked for accuracy and completeness. What measures will be put into place to ensure that the deficient practice does not recur: The Admission nurse will verify admission orders from the Hospital, review with the Attending Physician for accuracy, and transcribe to the resident's admission records. The RN Supervisor of the next shift will compare admission orders from the Hospital versus the ones on the resident's record. If noted with discrepancy, the MD will be notified for order clarification and will carry out the orders promptly. In addition, the RN Unit Manager/Designee will check again the next day if orders were carried out correctly by comparing orders and will sign the sheet to verify it was checked for accuracy. The DON/Designee will be notified of the findings for follow-up. How the facility plans to monitor its performance to make sure solutions are sustained: The facility will utilize QA tools every month for 3 months and quarterly thereafter. The results of the findings will be forwarded to the QA Committee monthly for follow-up and recommendations. The Designee will check again the next day if orders were carried out correctly by comparing orders and will sign the sheet to verify it was checked for accuracy. The DON/Designee will be notified of the findings for follow-up.
Failure to Uphold Resident's Financial Rights
Penalty
Summary
The facility failed to uphold a resident's right to manage their financial affairs, specifically concerning the handling of social security funds. Resident 2, who was cognitively intact and capable of making decisions, was not involved in the decision-making process regarding their financial affairs. The facility deposited Resident 2's social security checks into the Resident Fund Management Service (RFMS) account without the resident's knowledge or consent. This action was contrary to the facility's policy, which requires signed authorization from the resident or their authorized agent before making deposits into the RFMS account. The Business Office Director admitted that the facility did not inform Resident 2 about the deposits until after they were made and acknowledged the absence of a formal agreement allowing the facility to manage the resident's finances. The lack of documentation and communication resulted in Resident 2 losing control over their social security benefits, which were deposited without their consent. The Director of Nursing confirmed these findings, highlighting a significant lapse in the facility's adherence to its policies and procedures regarding resident financial rights.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident, leading to several deficiencies. The resident's Medication Administration Record (MAR) did not include documentation of lung sounds from October 4 to October 10, despite physician orders requiring this information to be recorded every shift. Additionally, there was no documentation of nursing actions taken after a low blood pressure reading of 91/49 mmHg was recorded on October 20. The resident's meal intake percentages were also missing for several days in October, and there was no documentation of monitoring for signs and symptoms of a urinary tract infection, as required by the care plan. Furthermore, the resident was on Bumex, a diuretic, which required monitoring for side effects such as dehydration. However, there was no documentation indicating that the resident was monitored for these side effects. The RN Unit Manager confirmed these documentation gaps during a concurrent closed medical record review and interview. These failures in documentation had the potential to impact the resident's care needs, as their medical information was incomplete and inaccurate.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for five residents, leading to deficiencies in the management and maintenance of respiratory equipment. Resident 440's CPAP machine was not maintained according to the manufacturer's guidelines, and the physician's order for the CPAP settings was not clarified, leaving the resident without specific inspiratory and expiratory settings. Additionally, there was no documented evidence of regular cleaning of the CPAP tubing assembly and water tub, which is crucial for preventing germ growth. Resident 55 received continuous oxygen at an incorrect rate, as the staff administered four liters per minute instead of the prescribed two liters per minute. The physician's order lacked specificity regarding the amount of oxygen to be administered, leading to inconsistencies in care. Furthermore, the resident's nasal cannula was not stored in a sanitary manner, posing an infection control risk. Similar issues were observed with Resident 98, whose nebulizer mask was not stored in a clean bag, and Resident 101, whose nasal cannula was left hanging on the bedside drawer without proper storage. Resident 27's nasal cannula tubing was found on the floor, and the resident reported being off oxygen for two days despite having a physician's order for oxygen administration. The tubing was not stored in a sanitary manner, and there was a lack of adherence to infection control protocols. These deficiencies highlight the facility's failure to ensure proper respiratory care and equipment maintenance, potentially affecting the respiratory health and well-being of the residents.
Failure to Implement Non-Pharmacological Interventions and Limit PRN Orders
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by the cases of four residents. For one resident, the facility did not limit the PRN order for an antipsychotic medication to 14 days, and there was no documented physician evaluation or justification for extending the use beyond this period. Interviews with the RN and DON confirmed these findings, indicating a lack of compliance with the facility's policy on psychotropic medications. Another resident did not receive non-pharmacological interventions prior to the administration of psychotropic medications, despite having orders for such interventions. The resident's MAR showed regular administration of medications like mirtazapine, fluoxetine, and eszopiclone, but non-pharmacological interventions were documented only once. Interviews with nursing staff confirmed the absence of documentation for these interventions, highlighting a failure to adhere to the care plan. A third resident's records showed a lack of non-pharmacological interventions before administering medications for anxiety and depression. The MAR and progress notes lacked documentation of these interventions, which were supposed to be implemented as per the care plan. Additionally, another resident did not have informed consent or a gradual dose reduction attempt for melatonin, and there was no specific monitoring for side effects of mirtazapine and melatonin. The DON confirmed these deficiencies, indicating a failure to follow the facility's procedures for psychotropic medication management.
Deficiency in Serving Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was served at appropriate temperatures, impacting the palatability and nutritional status of residents. During an initial tour, three residents reported that hot foods were not served hot, with one resident specifically mentioning items like fried eggs, bacon, pancakes, waffles, and egg sandwiches. A trayline observation revealed that the plate warmer was overfilled, with plates stacked above the heated compartment, which did not maintain the necessary temperature for hot foods. A test tray observation confirmed that several hot food items, including Pacific Rim Pork Roast, Red Beans and Rice, and Carrots with Parsley, were served at temperatures below the facility's policy requirements. The Dietary Services Supervisor (DSS) acknowledged that the metal hot plates, which were supposed to keep food hot, were not in use due to parts being ordered. The DSS admitted that the current use of plate warmers was insufficient to maintain the required temperatures for hot foods by the time they reached the residents. The Director of Nursing (DON), Registered Dietitian (RD), and DSS were informed of these findings.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as observed during an inspection. The inspection revealed that food items in the refrigerator were not properly labeled or dated, specifically a container of turkey meat that lacked an opened or use-by date. This was confirmed by the Dietary Services Supervisor (DSS), who acknowledged that the individual responsible for storing the food should have labeled it appropriately. Additionally, the facility did not maintain kitchen utensils in good repair or sanitary conditions. Several portion servers were found with partially melted handles and chipped surfaces, which were verified by the DSS. Furthermore, utensils set to air-dry were found with food particles and residue, and the drawer holding clean utensils contained white dry particles and water droplets. These findings were confirmed by the DSS, who took the items to be washed. The facility also failed to ensure that equipment and utensils were air-dried before storage. A blender and multiple metal pans were observed still wet and stored improperly, which could lead to cross-contamination. The DSS confirmed these observations and acknowledged that the items should have been completely dry before storage. The Director of Nursing (DON), Registered Dietitian (RD), and DSS were informed of these findings.
Failure to Notify Physicians of Inappropriate Antibiotic Use
Penalty
Summary
The facility failed to inform the physician of residents prescribed antibiotics when their signs and symptoms did not meet McGeer's Criteria for a true infection. This deficiency was identified for five of 30 final sampled residents and 24 nonsampled residents. The failure to notify the physician had the potential risk for continued use of unnecessary antibiotics, which could result in adverse reactions and the development of antibiotic-resistant bacteria. The facility's Antibiotic Stewardship Program (ASP) was designed to promote appropriate antibiotic use and optimize infection treatment while reducing adverse events. The program included monitoring antibiotic use, summarizing resistance patterns, and assessing residents for infections using standardized tools. However, the facility did not adhere to its policy of notifying physicians when residents were prescribed antibiotics without meeting the infection criteria. The Infection Preventionist (IP) was responsible for conducting surveillance and completing a Surveillance Data Collection Form for each resident with signs of infection. The IP was supposed to notify the prescribing physician if the criteria were not met, but documentation of such notifications was not found for the residents in question. The Director of Nursing (DON) acknowledged these findings during an interview.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, Resident 11 and Resident 98, were assessed for their ability to safely self-administer medications. Resident 98 was found with a tube of Preparation H and mometasone furoate at the bedside without a physician's order for self-administration. Despite having the capacity to make medical decisions, there was no care plan or assessment documented to address Resident 98's ability to self-administer these medications. Interviews with LVN 5 and the DON confirmed the absence of necessary documentation and procedures for self-administration. Similarly, Resident 11 had bottles of Lumify and Systane eye drops at the bedside, which she self-administered without a physician's order or assessment for self-administration. The medical record review showed no documentation of a care plan or assessment for Resident 11's ability to self-administer these medications. Interviews with LVN 10 and RN 3 revealed that they were unaware of the medications at the bedside and confirmed the lack of necessary orders and assessments. The facility's policy requires an interdisciplinary team assessment to determine if self-administration is clinically appropriate and safe. However, this process was not followed for Residents 11 and 98, leading to a potential risk of inappropriate medication use. The DON acknowledged the findings and the risk associated with medications being accessible at the bedside without proper authorization and assessment.
Failure to Timely Address Change in Condition
Penalty
Summary
The facility failed to conduct timely assessments and follow-up actions for a resident who experienced a change in condition. The resident, identified as Resident 138, had an episode of vomiting, abdominal discomfort, and refused to eat. Despite these symptoms, the facility did not promptly notify the physician or conduct a thorough assessment of the resident's abdominal pain. The initial vital signs were taken, but there was no documented evidence of subsequent monitoring or reassessment of the resident's condition. The facility's policy on significant change in condition requires that a nurse perform and document an assessment, notify the physician, and monitor the resident for at least three days. However, in this case, the physician was not notified until approximately three and a half hours after the change in condition was noted. Additionally, there was no evidence of further vital signs being taken or an assessment of the resident's abdominal discomfort, which was a critical oversight given the resident's symptoms. Interviews with facility staff, including an LVN, RN, and the DON, revealed that the staff were aware of the change in condition but failed to take appropriate and timely actions. The DON acknowledged the delay in notifying the physician and the lack of documented follow-up assessments. The resident's condition deteriorated, and they were found pale, cold, and clammy, with labored breathing, before being declared expired. This series of inactions and delayed responses contributed to the deficiency identified in the report.
Failure to Provide Pressure Ulcer Care and Equipment
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure injuries for Resident 840. The resident, who was unable to make medical decisions, was ordered by a physician to have a low air loss (LAL) mattress for wound management. However, observations on multiple occasions revealed that the resident did not have the LAL mattress in place as required. This lack of appropriate equipment was contrary to the facility's policy and the resident's care plan, which emphasized the use of pressure-relieving devices to prevent skin breakdown and promote healing. Additionally, the facility did not adhere to its policy of conducting weekly assessments of pressure injuries. The medical records showed inconsistencies in the documentation of the resident's pressure injuries, particularly the Stage 4 pressure injury on the thoracic spine, which was not assessed or documented as required on certain dates. This oversight in monitoring and documenting the resident's condition further contributed to the deficiency in care. Interviews with facility staff, including the LVN, SSD, and DON, confirmed the lapses in providing the LAL mattress and conducting proper assessments. The staff acknowledged the failure to follow up on the resident's need for the LAL mattress and the lack of documentation to support any follow-up actions. The DON verified that the facility should have provided the LAL mattress while waiting for insurance approval or delivery from the hospice company, highlighting a breakdown in communication and responsibility among the staff.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 91, was free from accident hazards by not placing floor mats on both sides of the resident's bed as ordered by the physician and outlined in the resident's care plan. This oversight was observed on two separate occasions, where Resident 91 was seen lying in bed without the required floor mats in place. The resident had a documented history of falls within the facility, with incidents occurring on multiple dates, and was assessed as being at high risk for falls. The care plan, which included the use of bilateral floor mats, was not adhered to, despite the resident's agreement with the plan. The facility's policy on fall management, revised in June 2018, mandates appropriate assessment and interventions to prevent falls and minimize complications. However, the failure to implement the physician's order for floor mats was confirmed during an interview with RN 3, who acknowledged the resident's fall history and the responsibility of supervisors to ensure fall interventions were followed. The Director of Nursing was also informed and acknowledged the findings, indicating a lapse in the facility's adherence to its fall management policy.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Residents 85 and 98, as per the physician's orders and facility policies. For Resident 98, the facility did not administer pain medication according to the prescribed parameters. The resident was given acetaminophen for pain levels that exceeded the mild pain threshold specified in the physician's order. This occurred on multiple occasions, with pain levels recorded between 4 and 6, which should have warranted the administration of tramadol instead. There was no documentation indicating that the physician was informed of these deviations from the prescribed pain management plan. For Resident 85, the facility did not consistently implement non-pharmacological interventions before administering narcotic pain medication as ordered. The resident's care plan included various non-drug interventions such as repositioning, dim lighting, relaxation, distraction, music, and massage, which were to be attempted prior to administering Dilaudid. However, the medical administration records for August, September, and October showed that these interventions were not documented as being attempted before the administration of the narcotic medication on several occasions. Interviews with facility staff, including an LVN and the DON, confirmed these findings. The LVN acknowledged the administration of pain medication outside the ordered parameters for Resident 98, and the DON confirmed that such practices could lead to ineffective pain management. Similarly, an RN confirmed the lack of documentation for non-pharmacological interventions for Resident 85, which was acknowledged by the DON.
Pharmacy Consultant Fails to Identify Irregularity in Diabetic Resident's Medication Review
Penalty
Summary
The Pharmacy Consultant at the facility failed to identify an irregularity in the medication regimen review for a resident with diabetes who was on insulin. The resident did not have any HbA1C level checked for 10 months, despite the physician's plan to routinely check the HbA1C every three to six months. The facility's policy and procedure for Medication Regimen Review, revised in August 2017, required the pharmacist to review each resident's medication regimen monthly to identify irregularities and unnecessary drugs. However, the Pharmacy Consultant did not make any recommendations regarding the HbA1C test for the resident from December 2023 to October 2024. During an interview, the Director of Nursing (DON) acknowledged the findings and stated that the frequency of the HbA1C test depended on the physician's order, which was not present in the resident's records. The DON also noted the potential serious complications that could arise from not monitoring the HbA1C levels, such as diabetic ketoacidosis, sepsis, and potential death. The Pharmacy Consultant, during a telephone interview, mentioned that recommendations about HbA1C were not usually made for residents on insulin in the long-term care setting, as it was considered more meaningful in outpatient care settings.
Improper Medication Storage and Expired Supplies Found in Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and treatment supplies, as evidenced by the observation of medications stored at the bedside of a resident without a physician's order or care plan. During an initial tour, a Licensed Vocational Nurse (LVN) observed a tube of CalaZinc cream, a spray bottle of Sea-Clens Wound Cleanser, and a tube of Critic-Aid skin paste in the bedside drawer of a resident. The resident's medical records did not show any physician's orders for these medications, nor was there a care plan addressing their use or storage at the bedside. Interviews with nursing staff confirmed that the medications were brought from home and that there was no authorization for their bedside storage. Additionally, the facility failed to remove expired treatment supplies from a medication cart. During an inspection of Treatment Cart 1, an expired culture swab was found, which had the potential to be ineffective or contaminated if used. The LVN responsible for the cart acknowledged missing the expired item during a previous check. The Director of Nursing (DON) confirmed that expired supplies should be immediately removed from the treatment cart to prevent potential risks.
Inappropriate Disinfection of Blood Pressure Cuff
Penalty
Summary
The facility failed to maintain safe infection control practices, as observed during a medication administration for a resident. A licensed nurse (LVN 1) was seen using Micro Kill One Germicidal Alcohol wipes to clean a wrist blood pressure monitoring device with a Velcro cuff. These wipes are intended for hard, non-porous surfaces, and not suitable for the blood pressure cuff, which is not a hard surface. LVN 1 confirmed the inappropriate use of the wipes and acknowledged that improper cleaning could lead to the spread of germs and bacteria, potentially causing serious health complications.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure the administration of the pneumococcal vaccine to a resident, identified as Resident 31, who was reviewed for immunizations. The facility's policy, revised in July 2023, mandates offering and administering vaccines, including pneumococcal, to eligible residents after obtaining consent. Resident 31, who lacked the capacity to make medical decisions, had a representative who consented to the pneumococcal vaccination on September 21, 2024. However, a review of the resident's immunization report on October 23, 2024, showed no evidence of the vaccine being administered. During an interview on October 23, 2024, the Infection Preventionist (IP) confirmed that the consent for the pneumococcal vaccine was obtained but the vaccine had not been administered. The IP explained that vaccines should be administered within five days of obtaining consent, but due to being busy during the influenza season, the pneumococcal vaccine was not given to Resident 31. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for a resident, identified as Resident 102, who resided in Room A. During an observation and interview, it was noted that the wall adjacent to Resident 102's bed was in disrepair, with visible scratches and areas where the paint was chipped. Resident 102 expressed a desire for her room to be neat and clean, as she spent a significant amount of time there, and indicated that the wall needed repair and repainting. The Director of Nursing (DON) was informed of these findings and verified the condition of the room.
Failure to Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident, identified as Resident 55, who was receiving continuous oxygen therapy. The care plan specified that oxygen should be administered at a rate of two liters per minute via nasal cannula if the resident's oxygen saturation levels were less than 90%. However, during an observation and interview with LVN 9, it was verified that the resident was receiving oxygen at a rate of four liters per minute, contrary to the physician's order and the care plan. The facility's policy and procedure, revised in May 2017, emphasized ensuring each resident receives quality care to maintain their highest practicable well-being according to the interdisciplinary comprehensive assessment and plan of care. Despite this policy, the discrepancy in the oxygen administration rate for Resident 55 was identified, posing a risk of not providing appropriate individualized care. The medical record review confirmed the physician's order and care plan, highlighting the failure to adhere to the specified oxygen administration rate.
Improper Garbage Storage Due to Broken Dumpster Lid
Penalty
Summary
The facility failed to ensure proper storage and coverage of garbage in one of its four dumpsters, which had the potential to attract pests and rodents that carry diseases. During an observation, it was noted that the right-side lid of one dumpster was missing, leaving the garbage exposed. The Maintenance Director confirmed that the lid had been broken since August 2024 and had not been repaired or replaced by the garbage company. Despite this, the dumpster continued to be used for garbage storage. The issue was acknowledged by the RD, DSS, and DON during a subsequent meeting.
Inadequate Communal Dining Space for Independent Residents
Penalty
Summary
The facility failed to provide sufficient space for communal dining for residents who did not require staff assistance with meals. During a resident council meeting, three residents expressed that only those needing assistance had access to the communal dining area, limiting their ability to socialize and affecting their quality of life. Residents expressed a desire for the option to eat in a communal setting rather than being confined to their rooms. The facility's administrator acknowledged the issue and indicated that efforts were underway to address the lack of communal dining space for these residents.
Deficient Care Planning for Residents' Medical and Mobility Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, addressing their specific medical and mobility needs. For Resident 2, the care plan did not include a problem statement for breast cancer treatment with Femara, a hormone-based chemotherapy medication. Additionally, the care plan for Resident 2's limited physical mobility lacked a measurable timeframe for achieving the goal of requiring minimal assistance with mobility tasks. This oversight was identified during a medical record review and an interview with Resident 2, who confirmed the ongoing use of Femara for breast cancer treatment. Similarly, the care plan for Resident 3, who required partial to moderate assistance with various mobility tasks, also lacked a documented target date for achieving the goal of minimal assistance. This deficiency was confirmed during a review of Resident 3's medical records and an interview with the Director of Nursing (DON), who acknowledged that the residents' medications should have been included in their care plans. These failures posed a risk of not providing appropriate, consistent, and individualized care to the residents.
Failure to Inform Resident of Change in Psychiatric Services
Penalty
Summary
The facility failed to ensure that Resident 1 was informed in advance and given the right to choose his treatment services when the facility changed his outpatient psychiatry services to in-house psychiatry services. Resident 1, who was cognitively intact and had the capacity to make decisions, was not notified or consulted about this change. The resident had been receiving weekly outpatient psychiatric services, but the facility unilaterally switched him to monthly in-house psychiatric services without his knowledge or consent. This change was confirmed through interviews with the resident, the Case Manager, and the Social Services Director (SSD), who all verified that there was no documentation showing Resident 1 was informed or agreed to the change in services. Resident 1 expressed that he did not agree with the change and would have preferred to continue with his weekly outpatient psychiatric services. The Case Manager justified the change by stating that since the facility provided in-house psychiatry and psychology services, there was no reason to send the resident out weekly for his appointments. However, the lack of communication and failure to obtain Resident 1's consent for this change in his treatment plan was acknowledged by the Director of Nursing (DON) during a follow-up interview. This oversight had the potential to prevent the resident from participating in his treatment decisions, as required by the facility's policy on Resident Rights.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orange Healthcare & Wellness Centre, Llc | 0.6 mi | ★★★★★ | 27 | 0 |
| Town & Country | 0.7 mi | ★★★★★ | 27 | 0 |
| Healthbridge Children's Hospital - Orange D/p Snf | 1.7 mi | ★★★★★ | 18 | 0 |
| French Park Care Center | 1.8 mi | ★★★★★ | 51 | 0 |
| Citrus Post-acute | 2.1 mi | ★★★★★ | 6 | 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.