Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission Valley Post Acute during CMS and state inspections, most recent first.
An unlicensed OM was found acting as the facility administrator for more than two years, despite state records showing a different reported administrator and a posted NHA license holder who was not present. OM signed grievance logs and QAPI documents as administrator, introduced himself that way, and staff and a resident confirmed he was directing facility operations. State license review showed OM did not hold an active NHA license, while the NHAH stated OM should not have been calling himself the administrator.
Incomplete and Inaccurate Controlled Medication Records: The DON, ADON, MRD, and RN described a controlled substance process using Shipping Manifests, CDRs, and MARs, but surveyors found missing Shipping Manifests for multiple residents’ oxycodone and hydrocodone/APAP deliveries. Staff also acknowledged several CDR medication removals did not match MAR documentation for selected residents. The consultant pharmacist’s review reports did not document issues with the controlled medication records, despite the facility policy requiring the records to be complete and accurate.
Unsafe room conditions and unclean oxygen equipment: Wet floors without caution signage were observed in shared resident rooms, along with clutter and spilled items on the floor, including a spoon, yogurt, a cup, a toothbrush, and visible white particles. One resident with cerebral infarction and Alzheimer’s disease was seen unattended while trying to rise from a wheelchair, and RN 1 stated the room should have been kept clean. Another resident’s oxygen concentrator had dust on the top surface, which CNA 3 and CS confirmed, and the DON stated the rooms should be tidied and cleaned daily.
A resident with MRSA pneumonia and acute respiratory failure became very sleepy and hard to awaken, but the chart did not show a timely nursing assessment, current VS, or an SBAR that reflected the change in mental status; the resident was later found unresponsive with mucus, abnormal VS, and transferred to the hospital. Two other residents with orders for daily weights had problems with weight monitoring: one had repeated documented refusals without reason or MD/family notification, and another had a large recorded weight drop without reweighing or documented verification of the change.
Pharmaceutical services were not provided as ordered when a resident’s routine dapagliflozin was unavailable for 3 days, and staff did not document controlled substance administration correctly for multiple residents. Two residents had Norco or Roxicodone signed out of the CDR without MAR documentation, one resident received PRN Norco when the pain score was zero, and another resident had Roxicodone documented on the MAR without a corresponding CDR removal. The DON and ADON reviewed the records and confirmed the documentation and administration issues.
Improper food storage and sanitation were observed when milkshakes were kept in a broken freezer that was not maintaining the required temperature, baked goods and frozen potato wedges were stored in a warm emergency storage room, and clean water pitchers were placed next to a dirty coffee drainpipe with visible residue. The DM acknowledged the freezer was broken, the room temperature was not being monitored, and the pitchers were stored in an area with dirt and cross-contamination concerns.
Multiple infection control failures were observed involving resident items, laundry handling, sharps storage, wound care, and shared devices. A resident’s clothing that had been on the floor was returned to the closet with clean clothing, another resident’s urinal was stored on a trash receptacle without a lid or protective bag, and laundry staff transported uncovered soiled linens through the hallway while wearing contaminated PPE and entering the clean laundry area. Staff also observed an overfilled sharps container, an LPN failing to perform hand hygiene during wound care, uncapped feeding tubing, an uncovered nebulizer mask, and an RN disinfecting shared glucometers with alcohol swabs instead of the facility’s bleach disinfectant.
Freezer 3 was found with a missing louvered panel and a missing right handle. The exposed wiring, coils, and mechanical parts were visible and coated with black sticky dust, and the DM said the panel had been missing for about a year while the handle had been broken for a long time and not reported to the MD. The facility policy required refrigerators and freezers to be kept in good working condition and inspected monthly for damage or maintenance needs.
A resident with left-sided hemiplegia/hemiparesis, weakness, and aphasia had a care plan directing staff to keep the call light within reach, but during observation the call light was placed out of reach near the resident's weak side. The resident was seated in a wheelchair with the left arm unsupported and slumped, reported left-side pain, and requested repositioning; the DON later stated the call light should have been on the resident's right side within reach.
Failure to Quantify Behavior Monitoring for Antipsychotic Use: A resident with unspecified dementia and depression was receiving Olanzapine for angry outbursts, but staff did not document a numeric count of the target behavior on the MAR. Instead, nursing entered only check marks each shift, and the DON and ADON confirmed the facility was not monitoring the number of episodes as a measure of response to the antipsychotic or for use in quarterly psychotropic review and possible GDR consideration.
A resident with depression and stomach cancer had significant weight loss and poor intake, with staff reporting she usually ate only about 25% to 50% of meals. After a documented 11.8% weight loss, the resident was not reweighed for 20 days, despite the DON and RD acknowledging that ongoing weight monitoring should have occurred and the facility policy requiring prompt recheck of significant weight changes.
Respiratory Care Not Provided as Ordered: Two residents did not receive respiratory support as ordered. One resident with COPD, bronchiectasis, and O2 dependence had BiPAP therapy that was not applied and maintained correctly, and staff could not identify the ordered settings or determine whether the device was malfunctioning. Another resident with Alzheimer’s disease and asthma had continuous O2 ordered at 3 L via nasal cannula, but the cannula was found under the chin instead of in the nostrils while the concentrator remained on.
Two residents had unnecessary drug regimen concerns. One resident with HTN and atrial fibrillation received metoprolol without hold parameters in the order, and the ADON confirmed instructions were needed for when BP or HR were too low. Another resident with hypothyroidism received levothyroxine without facility TSH monitoring, and the DON and ADON confirmed there were no TSH values in the record despite a prior low hospital TSH result.
A facility failed to ensure the accuracy of a Level I PASARR screening for a resident with a history of psychological disorders and receiving antipsychotic medication. The PASARR inaccurately indicated no serious mental disorder, contrary to the resident's documented diagnoses. Staff interviews revealed the MDS Coordinator was responsible for verifying PASARR accuracy, and the facility policy required screening for mental disorders, with further evaluation if necessary.
The facility was found non-compliant with room size requirements, as rooms on Station 3 were below the 80 sq ft per resident standard. Staff reported no care issues due to room size, but the Administrator and DON acknowledged the importance of meeting these standards.
A facility failed to meet professional standards when nursing staff did not document or follow physician's orders for a resident, leading to the worsening of a sacrococcyx wound from Stage 1 to Stage 4. The DON confirmed the deficiency, noting that proper documentation and adherence to orders were not maintained.
Unlicensed OM Functioned as Administrator
Penalty
Summary
The facility failed to ensure that the administrator who supervised and directed facility operations was licensed according to state regulation. Surveyors found that the unlicensed Operations Manager (OM) had been functioning in the administrator role for more than two years and five months, while the facility’s posted nursing home administrator license holder was not present at the facility. The post board near the nurses station identified a nursing home administrator license holder, but the OM was the person signing and presenting himself as the administrator. Record review showed that two facility financial reports submitted to the state agency for 12/31/23 and 12/31/24 listed OM as the administrator and did not list the Reported Administrator (RA). State agency database review showed RA was reported as the facility’s administrator from 3/2023 to 5/2025, while the state nursing home administrator license database showed OM did not have a nursing home administrator license. The facility screening log also listed OM as administrator, and OM’s business card identified him as Administrator. During interview, OM stated he was responsible for grievances, signed grievance logs as administrator, and said he started as administrator in 3/2023. Interviews with staff and residents confirmed OM was acting in the administrator role. The DON and ADON stated OM had been the administrator for almost three years since the operating organization purchased the facility. Resident 9, who had heart failure, kidney disease, and respiratory failure, had a BIMS score of 15 and was alert and oriented; Resident 9 stated OM was the administrator and that he spoke with OM frequently. The DON stated OM was the administrator at QAPI meetings, and monthly QAPI documents from 1/2025 through 6/2025 showed OM signed in as administrator. OM later stated the NHAH was the administrator of the building, while the NHAH stated they were the reported administrator from 4/2025 to 8/2025 and were unaware of OM acting as the facility administrator.
Incomplete and Inaccurate Controlled Medication Records
Penalty
Summary
The facility failed to ensure that its controlled medication record system was complete and accurate for Residents 1 through 8. During interviews and record review, the DON, ADON, MRD, and RN described a process in which scheduled medications were delivered with a Shipping Manifest, documented on a corresponding CDR, administered per the MAR, and retained in the facility records. However, when the surveyors requested the Shipping Manifests and CDRs for the identified residents, the facility could not locate the corresponding Shipping Manifests for multiple controlled medication deliveries. The missing Shipping Manifests involved controlled medications for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, and Resident 8. The identified CDRs included deliveries of oxycodone and hydrocodone/APAP in various strengths and quantities. Facility staff acknowledged that the Shipping Manifests could not be found, despite their stated expectation that these records were retained by the facility as part of the controlled substance documentation system. Surveyors also compared selected CDR medication removals with the MAR and found that several removals did not have corresponding MAR documentation at the listed dates and times. This included records for Resident 6, Resident 7, Resident 1, Resident 8, and Resident 2. The DON, ADON, and MRD acknowledged these mismatches during the record review. The facility policy for controlled substances required the documentation to be complete and accurate, and the consultant pharmacist’s monthly review reports for June, July, and August 2023 did not document issues with incomplete or inaccurate scheduled medication records, although random narcotic audits were completed in June and August 2023 with no documented findings.
Unsafe Room Conditions and Unclean Oxygen Equipment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for five sampled residents when wet floor surfaces, clutter, and dust were observed in resident rooms. In the shared room of two residents, the floor area between the beds was wet, and no caution or wet-floor signage had been placed to alert residents, staff, or visitors. One resident’s responsible party was present and was told to proceed with caution because of the wet floor surface. In another shared room, a resident with diagnoses including cerebral infarction and Alzheimer’s disease was observed seated in a wheelchair and attempting to rise up while unattended. Under the bed were a plastic spoon, spilled white liquid, and a cup of yogurt. Between the two beds, a clear plastic cup was on the floor mat next to a wet floor surface under the other bed, and no caution or wet-floor signage had been placed. A white toothbrush and visible white particles were also on the floor near the edge of the bed. The resident stated the room’s condition was not good and said they did not like the items on the floor. RN 1 stated staff should have been checking on the resident and addressing needs, including maintaining cleanliness of the room, and stated the floor should not have been wet because it had the potential to cause injury including falls. A third resident’s room contained an oxygen concentrator connected to a nasal cannula, and the top surface of the concentrator had white powder-like particles. CNA 3 wiped the particles with a finger and identified them as dust, and CS later confirmed the particles were dust and stated she was responsible for maintaining the cleanliness of the oxygen at least weekly but had not yet cleaned it. The DON stated the rooms should be kept tidied and cleaned every day and that the facility should have provided a home-like environment to the residents because the facility was their home. Facility policies stated residents are to be provided with a safe, clean, comfortable, and homelike environment and that floors shall be maintained in a clean, safe, and sanitary manner.
Failure to assess change in condition and monitor ordered daily weights
Penalty
Summary
Resident 1 had a change in condition that was not promptly assessed or evaluated after being observed very sleepy and difficult to awaken following return from an out-on-pass visit. The resident’s record showed a progress note documenting that the resident was very sleepy and did not respond until multiple attempts were made to awaken the resident, but no vital signs were documented on that date. An SBAR communication form completed later did not include the resident’s change in mental status and instead contained copied vital signs from the prior day rather than current findings. The resident’s record also showed that the next morning the resident was found unresponsive with a large amount of mucus, elevated blood pressure, elevated pulse, oxygen saturation of 82%, and altered level of consciousness, and the resident was transferred to the acute care hospital via 911. The resident had diagnoses including pneumonia due to MRSA and acute respiratory failure with hypoxia. During interview, the resident stated the facility did not provide timely nursing interventions when the resident became ill, and the DON confirmed that no assessment, including vital signs, was performed when the resident exhibited the change in condition. Resident 10 had a physician order for daily weights in the morning at the same time, in the same clothing, and on the same scale, with notification required for specified weight variance. The record showed repeated refusals of weight measurements on multiple days, but the notes did not document the reason for the refusals or physician and family notification. Staff interviews showed conflicting information about whether the resident actually refused weights, and the DON confirmed that physician notification was not documented despite repeated refusals. Resident 95 also had a physician order for daily weights due to CHF, with instructions to notify the physician for significant weight variance. The resident’s recorded weights showed a sudden drop from 93 lbs. to 88.8 lbs. and then to 79.8 lbs. The DON stated the resident should have been reweighed to verify accuracy and that the physician should have been notified if the weight change was confirmed. The facility’s records showed the weight changes were documented, but the required verification and notification were not shown in the record.
Medication Availability and Controlled Substance Documentation Failures
Penalty
Summary
Pharmaceutical services were not provided to meet resident needs when a routine medication was unavailable for Resident 67 for 3 days. During a medication administration observation, the RN stated she did not have dapagliflozin available to give, and later called the physician to report the medication was still not available. The resident had an order for dapagliflozin 5 mg daily, and nursing progress notes documented that the medication was not available on 5/15/26 and was still awaiting delivery on 5/16/26 and 5/17/26. The RN later confirmed the medication was not administered during that 3-day period, and the DON and ADON verified the missed doses and could not find documentation that nursing staff had called the pharmacy when the medication ran out. Controlled substance documentation was inaccurate for multiple residents. For Resident 49, the record showed Norco 5/325 mg was signed out of the CDR on two occasions, but the MAR did not document administration on those dates. For Resident 95, the record showed Roxicodone 5 mg was signed out of the CDR on two occasions, but the MAR did not document administration on those dates. The DON and ADON reviewed the records and confirmed the controlled medications were removed from inventory without corresponding MAR documentation. An as-needed pain medication was also administered without the documented pain indication for Resident 39. The resident had an order for Norco 5/325 mg every 12 hours as needed for moderate pain, but the MAR showed doses were given when the pain score was zero. In addition, Resident 36 had Roxicodone documented as administered on two occasions on the MAR, but there was no removal of the medication from the CDR, leaving it unknown where the medication came from. The DON acknowledged the documentation issue after speaking with the nurse, and the facility policy required medications to be administered in accordance with prescriber orders and documented on the MAR, with controlled substances reconciled through the MAR.
Improper Food Storage and Sanitation
Penalty
Summary
Food was not stored and prepared in accordance with professional standards when three boxes of 4-fluid-ounce milkshakes were found in Freezer Chest 4 even though the freezer was not maintaining the required temperature. During the initial kitchen tour, the boxes were observed in the freezer, which was reading negative 4 degrees F at first, but the unit felt warm and later rechecked at 20 degrees F. The Dietary Manager stated the freezer should be at 0 degrees F or below and acknowledged that Freezer Chest 4 was broken. The Maintenance Director stated he only performed visual checks on the freezer and had no documentation of maintenance for it. Food storage practices were also deficient in the emergency storage room and kitchen. An unopened box of blueberry muffins and two unopened bags of frozen potato wedges were stored on top of Freezer Chest 5 in a room that felt warm, and the Dietary Manager stated the room temperature was not being monitored. The blueberry muffins were measured at 48.9 degrees F, and the Dietary Manager stated they should be at 41 degrees F and that storing them at room temperature created a risk of food spoilage. In the kitchen, clean water pitchers were stored next to a dirty coffee drainpipe with brown and black residue on it; when wiped with a moist paper towel, brown residue was picked up. The Dietary Manager acknowledged the residue was dirt and stated the pitchers should not have been stored there because of the risk of cross contamination.
Infection Control Failures With Linen, Resident Items, Sharps, Wound Care, and Shared Devices
Penalty
Summary
The facility failed to follow infection prevention and control practices for multiple residents and shared equipment. Resident 9, who was admitted with diagnoses including unstable angina and a personal history of Covid-19, had a light gray pair of pants observed on the floor in front of the closet and later returned to the closet with clean clothing without being laundered or cleaned first. The facility’s Infection Preventionist/Director of Staff Development stated clothing found on the floor should have been removed, placed in a plastic bag for laundering, and not returned to the closet because germs on the floor could transfer to clean clothing. Resident 86, who was admitted with dysphagia following a nontraumatic intracerebral hemorrhage, had a urinal without a lid and not stored in a protective bag hanging on the side of a trash receptacle near the bathroom entrance. A CNA removed the urinal from the trash receptacle during the observation. The Infection Preventionist/Director of Staff Development stated urinals not in use should be stored in a plastic bag with a lid near the bedside, and that placing the urinal on the trash receptacle could contaminate it from waste or contaminated items inside the receptacle. In the laundry area, Housekeeping/Laundry Personnel transported an uncovered gray laundry barrel containing soiled linens through the hallway while wearing PPE, then entered the clean area of the laundry room without removing the contaminated PPE. The same staff member crossed the demarcation line between dirty and clean areas while handling the soiled laundry barrel. The Housekeeping Manager and DON stated the barrel should have remained closed, should not have crossed into the clean area, and contaminated PPE should have been removed before entering the clean area. The facility also observed an overflow medication cart with a sharps container filled beyond the manufacturer’s fill line, with sharps extending above the line and other metal objects inside. The LVN stated the sharps container should have been replaced when full, and the DON stated sharps containers must be replaced once they reach the fill line. Additional infection control failures were observed during resident care and equipment use. During wound care for Resident 13, an LVN removed a soiled dressing from the coccyx and did not perform hand hygiene before putting on new gloves, then cleansed the wound and applied treatment without changing gloves during cleansing and without hand hygiene after glove removal. Resident 70’s feeding tubing was observed uncapped and exposed, and Resident 16’s nebulizer mask was observed uncovered and not stored in a protective bag. During blood sugar monitoring, an RN used alcohol swabs to wipe shared glucometers after resident use, while the IP/DSD and DON stated the glucometers should be disinfected with SaniCloth Bleach wipes after each use.
Freezer 3 Missing Parts and Poor Maintenance
Penalty
Summary
Freezer 3 was not maintained in proper working condition because its louvered panel was missing and its right handle was missing. During observation with the Dietary Manager, the missing louvered panel left the wiring, coils, and mechanical parts underneath exposed, and the exposed components were coated with scattered black sticky dust; the Dietary Manager stated the panel had been missing for one year. During interview, the Maintenance Director stated he was unsure when the panel was damaged and noted the risk of food contamination if the freezer stopped working due to the missing part that protected the freezer's mechanical components. The Dietary Manager also showed that the freezer's right side handle was missing and stated it had been broken for a long time and was not reported to the Maintenance Director. The Maintenance Director stated he was unsure when the handle was damaged and that it should have been fixed. The facility policy stated refrigerators and freezers are to be maintained in good working condition and inspected monthly for damage or maintenance needs, with necessary repairs initiated immediately.
Call Light Left Out of Reach for Resident With Left-Sided Weakness
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not maintained for Resident 70 when the call light was left out of reach. Resident 70 was admitted with diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side, difficulty walking, weakness, and aphasia. The MDS dated 4/13/26 indicated impairment on one side of the body affecting both upper and lower extremities, and that the resident was usually understood and usually understood most conversation, though had difficulty communicating some words or finishing thoughts. Resident 70's fall care plan dated 4/9/26 directed staff to keep the call light and personal items within reach. During observation on 5/18/26 at 12:00 p.m., Resident 70 was in a wheelchair positioned on the far-left side of the bed, with the left side from shoulder to hand slumped without support and unable to lift the left hand. The call light was placed on the right side of the bed near Resident 70's left side, and the resident reported left side pain and requested repositioning. During interview on 5/19/26 at 2:10 p.m., the DON stated the call light should be on the right within Resident 70's reach because the resident could not access it if placed on the left weak side.
Failure to Quantify Behavior Monitoring for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that one sampled resident with unspecified dementia and depression was free from unnecessary psychotropic medication use. The resident had been receiving Olanzapine 10 mg at bedtime for unspecified dementia manifested by angry outbursts since 4/3/25, and there was a physician order to monitor the specific behavior of angry outbursts every shift and chart the number of episodes. A review of the resident’s MARs for February, March, April, and May 2026 showed that nursing staff placed only a check mark in the behavior-monitoring entry each shift, with no quantitative count of episodes documented. During a concurrent interview and record review, the DON and ADON confirmed that the facility had not been monitoring the number of angry outbursts as a response to Olanzapine treatment, and they acknowledged that the number of target symptoms and behaviors would be used by the interdisciplinary team to assess whether to recommend a GDR during the quarterly psychotropic medication review.
Failure to Reweigh Resident With Significant Weight Loss
Penalty
Summary
The facility failed to ensure continued nutritional care and services for a resident who had significant weight loss and was not reweighed after 5/1/26 for 20 days. Resident 68 was admitted with diagnoses including depression and malignant neoplasm of the stomach, and the MDS dated 3/27/26 showed a BIMS score of 12, indicating moderate cognitive impairment. The resident’s weight trend showed a decline from 94.8 lbs. on 3/28/26 and 94.6 lbs. on 4/6/26 to 83.4 lbs. on 5/1/26, reflecting an 11.2 lb. loss and 11.8% weight loss from 4/6/26 to 5/1/26. During an observation on 5/18/26, Resident 68 was lying in bed asleep and her meal tray was untouched at the bedside. CNA 5 stated that over the prior two months the resident usually ate around 25% and no more than 50% of breakfast and lunch. The DON acknowledged that the resident should have been weighed weekly to monitor for further weight loss, and the RD stated the resident should have been reweighed at least biweekly after 5/1/26, but no weight record was found after that date. The facility’s Weight Assessment and Intervention policy stated that any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation.
Respiratory Care Not Provided as Ordered
Penalty
Summary
Respiratory care was not provided in accordance with professional standards for two residents. One resident with COPD, bronchiectasis, and dependence on supplemental oxygen had an order for BiPAP at bedtime, but the BiPAP equipment was not applied and maintained as ordered, and staff did not follow required procedures for monitoring or troubleshooting the device. The resident stated the BiPAP did not function properly the previous night, that he needed more oxygen and was unable to breathe, and that his concern was not addressed. He also stated that about 40 minutes after starting the BiPAP, his oxygen saturation dropped to 85%. During observation and interview, an RN stated the BiPAP was typically turned on before leaving for the day, but the physician’s order did not specify settings and the RN could not identify the required settings or locate them on the machine. The RN said she was responsible for filling the water reservoir and was unsure how to determine whether the BiPAP was malfunctioning. The DON stated the order lacked BiPAP settings, the hospital discharge records also did not indicate the settings, and the vendor set up the machine. The facility’s policy required staff to review the resident’s record for baseline respiratory status and physician’s orders for oxygen concentration, flow, and pressure settings before initiating therapy. A second resident with Alzheimer’s disease and asthma had an order for oxygen at 3 liters per minute via nasal cannula continuously, and the care plan also indicated oxygen via nasal prongs at 3 liters continuously. During observation, the oxygen concentrator was powered on, but the nasal cannula was under the resident’s chin rather than positioned in the nostrils. The LVN reapplied the cannula and stated the resident frequently removed it and that nursing staff should have performed frequent monitoring to ensure it remained in place. The DON stated oxygen should have been provided continuously as ordered and that nursing staff should have monitored cannula placement at least every two hours, or more frequently as needed for residents with confusion, to ensure oxygen therapy was being administered.
Unnecessary Drug Regimen Due to Missing Hold Parameters and TSH Monitoring
Penalty
Summary
The facility failed to ensure that two sampled residents were free from unnecessary drugs. One resident with atrial fibrillation and hypertension had an order for metoprolol 25 mg by mouth each morning for hypertension, but the physician’s order did not include hold parameters. During a concurrent interview and record review, the ADON reviewed the resident’s May 2026 MAR and confirmed there should have been instructions for when to hold the medication, such as when BP or HR were below certain readings, to avoid them being too low. Another resident with hypothyroidism had been receiving levothyroxine 150 mcg every morning since readmission, but the record contained no TSH monitoring related to levothyroxine use. The ADON initially could not find any TSH laboratory values, then identified a hospital TSH result of 0.03 from a prior hospital stay. The DON and ADON confirmed the resident had continued on levothyroxine 150 mcg daily without TSH monitoring since returning to the facility, and the facility was not aware of the hospital’s low TSH level while the resident was hospitalized.
Inaccurate PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure the accuracy of a Level I Preadmission Screening and Resident Review (PASARR) for a resident admitted with a medical history that included unspecified disorder of psychological development, unspecified psychosis, and depression. Upon admission, the resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and active diagnoses of depression, psychotic disorder, and unspecified disorder of psychological development. The resident was also receiving antipsychotic medication, Risperdal, for unspecified psychosis. However, the PASARR Level I screening inaccurately indicated that the resident did not have a serious mental disorder, which was contrary to the resident's documented diagnoses and medication regimen. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the MDS Coordinator was responsible for verifying the accuracy of the PASARR upon a resident's admission. Both the MDS Coordinator and the DON acknowledged that the resident's diagnosis of psychosis should have been reflected in the Level I PASARR screening. The facility's policy required that all new admissions be screened for mental disorders, and if the Level I screen indicated potential criteria for a mental disorder, a Level II evaluation should be conducted. The failure to accurately complete the Level I PASARR screening could result in the omission of necessary evaluations and services for the resident.
Non-compliance with Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that residents' rooms met the minimum size requirements, with several rooms measuring less than the required 80 square feet per resident. Specifically, rooms 27 to 34 on Station 3 were found to be non-compliant, with each room providing only 70 to 78.75 square feet per resident. This deficiency was confirmed by the Maintenance Director during measurements conducted on 10/10/2024. Interviews with staff, including CNAs and a Licensed Vocational Nurse, revealed that they did not experience any issues providing care due to the room sizes. However, the Administrator acknowledged the importance of adhering to room size requirements to ensure that care is not impeded. The Director of Nursing also expressed an expectation that the facility should comply with the regulatory standards for room sizes, indicating awareness of the 80 to 100 square feet requirement.
Failure to Document and Follow Physician's Orders
Penalty
Summary
The facility failed to provide services that met professional standards for one resident when nursing staff did not document that physician's orders were carried out. This failure contributed to the formation and worsening of the resident's sacrococcyx wound. The resident was admitted with diagnoses including mitral valve insufficiency and traumatic hemorrhage of the cerebrum. The resident's Braden Scale assessment indicated a very high risk for developing a pressure injury, and the physician's orders included the application of barrier cream, foam dressing, and position changes to prevent further skin deterioration. Despite these orders, the Treatment Administration Records (TAR) for February through June 2023 showed numerous instances where the prescribed treatments were not documented as carried out. Specific orders such as cleansing the coccyx area, applying barrier cream, and using an air mattress were frequently not followed across multiple shifts. This lack of documentation and adherence to physician's orders was confirmed by the Director of Nursing (DON), who acknowledged that if it was not documented, it was not done. The resident's condition worsened over time, with the sacrococcyx area developing from a Stage 1 pressure injury to an unstageable wound and eventually a Stage 4 pressure ulcer. The facility's policies on medication and treatment orders, as well as the prevention of pressure injuries, were not followed, leading to the resident's deteriorating condition. The DON confirmed the deficiency, stating that it was the licensed nurse's responsibility to ensure orders were carried out and documented properly.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| We Care Skilled Nursing - Fremont | 0.1 mi | ★★★★★ | 3 | 0 |
| Country Drive Post Acute | 0.1 mi | ★★★★★ | 4 | 0 |
| Crestwood Treatment Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Niles Canyon Post Acute | 0.9 mi | ★★★★★ | 6 | 0 |
| Fremont Healthcare Center | 1.2 mi | ★★★★★ | 22 | 0 |
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