Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montecito Heights Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Two residents receiving opioid pain medications did not have their pain levels or vital signs assessed and documented as required by physician orders and facility policy. Pain reassessment after medication administration was not completed within the required timeframe, and pre-administration assessments were inconsistently performed, resulting in inadequate monitoring and documentation of pain management.
Surveyors found that boxed food items were stored directly on the floor and a dispensing scoop was left inside a salt container, contrary to facility policy requiring food to be stored at least six inches off the floor and scoops to be stored separately for infection control.
A resident with multiple chronic conditions and cognitive intactness was not provided with a Notice of Medicare Non-Coverage (NOMNC) when the facility initiated discharge from Medicare Part A skilled services. Staff interviews and record review confirmed the NOMNC was not given, despite facility policy and CMS guidelines requiring notification prior to the end of covered services.
Two residents were affected by inaccurate MDS assessments: one was incorrectly documented as using trunk restraints despite staff and observation confirming no restraints, and another was inaccurately assessed as frequently incontinent and not on a bowel/bladder program, despite being generally continent and expressing a need for scheduled toileting assistance. These discrepancies between MDS documentation and actual resident status were confirmed by staff and had the potential to impact care.
A resident admitted with ESRD, hypertension, and a left femoral permcath for dialysis did not have their dialysis access site addressed in the baseline care plan, despite physician orders to monitor the site and facility policy requiring comprehensive care planning within 48 hours. Both nursing staff and the DON acknowledged the omission of this critical information from the care plan.
Two residents did not have individualized, person-centered care plans developed to address their specific needs. One resident with severe cognitive impairment and frequent incontinence had a care plan that only included medication administration, lacking other necessary interventions. Another resident with dementia and an order for oxygen therapy did not have a care plan addressing oxygen use. Staff confirmed that these care plans were insufficient and did not meet facility policy requirements.
A resident with impaired mobility and multiple risk factors for pressure injuries was not provided with bilateral heel protectors as ordered by the physician and outlined in the care plan. Instead, the resident's heels were placed on a pillow while in bed. Both an LVN and the DON confirmed the omission, which was not in accordance with facility policy for pressure injury prevention.
A resident with a seizure disorder, paraplegia, and other medical conditions was not provided with bilateral padded side rails as ordered by the physician for seizure precautions. Despite care plans and facility policy requiring this intervention, observations and staff interviews confirmed the absence of padding on the bedrails, placing the resident at risk for injury.
Two residents did not receive appropriate urinary and bowel care services, including failure to maintain continence support for a resident with a history of UTIs and improper catheter management for another resident, resulting in a dependent loop and urine backflow. These deficiencies were inconsistent with facility policies aimed at preventing UTIs and skin breakdown.
Two residents receiving oxygen therapy did not receive care according to facility protocols: one resident's oxygen humidifier bottle was allowed to run empty despite continuous use and a stated need for humidification, while another resident's nasal cannula was not labeled with the date of last change as required. Staff interviews and observations confirmed these lapses, which were not in line with the facility's policies for respiratory care.
A resident with ESRD and a left femoral permcath for hemodialysis did not receive proper assessment and monitoring of the dialysis access site, as required by facility policy. Admission documentation was inaccurate regarding the resident's dialysis status and access site, and pre and post dialysis assessments were incomplete on multiple occasions, failing to include necessary evaluations of the access site.
Two rooms were found to exceed the regulatory limit of four residents per room, with one room housing seven beds and another five beds. Observations and interviews with a resident and a CNA indicated that there was adequate space for care and movement, and all residents had privacy curtains, call-lights, dressers, and bedside tables.
A facility failed to monitor the placement and functionality of bed and wheelchair alarms for a resident with dementia and mobility issues. Although physician orders were given to apply these alarms for safety, monitoring did not begin until several months later. Staff interviews confirmed the delay, and the facility's policy required regular checks and documentation of these devices.
A resident with a history of CHF and hypertension was found with an altered level of consciousness and low oxygen saturation. The facility failed to provide adequate oxygen therapy, initially administering only 4L via nasal cannula instead of a non-rebreather mask. Paramedics later corrected this, improving the resident's condition. Documentation of the oxygen therapy was lacking, contrary to facility policy.
Two residents signed Assisted Living Waiver forms in a language they did not understand, resulting in them and their families being unaware of the contents. Despite being cognitively intact and preferring communication in their own language, the facility provided the documents in English without proper interpretation. Interviews revealed that neither the residents nor their families received copies of the signed documents, contrary to the facility's policies on resident rights and translation services.
A resident scheduled for discharge to a lower level of care did not receive the required Notice of Proposed Transfer and Discharge. Despite being cognitively intact and needing assistance with daily activities, the resident was not informed in writing about the discharge date and reasons. The DON confirmed the oversight, which was against the facility's policy requiring notice 30 days prior or as soon as practicable.
The facility did not post the actual daily hours worked by staff for four days in June 2024, displaying only projected hours instead. This was confirmed by the DSD, who stated that actual hours were kept in a separate binder. The facility's policy requires posting actual nursing hours to ensure patient safety and adequate staffing.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with hemiplegia had the call light on the floor, while another with muscle weakness had it hanging far away. Staff confirmed the inaccessibility, contradicting the facility's policy requiring call lights to be within reach.
The facility failed to update care plans for two residents after discontinuing treatments. One resident's care plan was not revised to reflect the end of antibiotic therapy, while another's was not updated after the removal of an indwelling catheter. This oversight was confirmed through record reviews and staff interviews, highlighting a deficiency in care planning.
A resident with Type 1 diabetes did not receive insulin injections in accordance with professional standards, as the facility failed to rotate the injection sites as ordered by the physician. The resident received Basaglar injections in the same site on the right arm for four consecutive days, contrary to the physician's instructions and facility policy, which required site rotation to prevent skin complications.
A resident continued to receive Enoxaparin, a blood thinner, without a physician's order due to a failure in communication and follow-through by the DON. Despite a pharmacist's recommendation to discontinue the medication, it was administered daily, placing the resident at risk for adverse effects. The oversight was discovered during a surveyor interview, highlighting a lapse in following the facility's medication administration policies.
A resident with dementia and dysphagia was served coffee with a thin consistency instead of the prescribed nectar thick liquid, contrary to the Physician's Order. The error was acknowledged by a CNA, and both the RD and DON confirmed the importance of following the therapeutic diet to prevent choking and aspiration risks.
A resident with hemiplegia and other conditions was not provided with a dycem, a non-slip mat, during meals as required by their care plan. Despite having a divided plate, the dycem was missing, which was confirmed by the resident and observed by surveyors. Facility staff acknowledged the importance of the equipment, but records showed it was not consistently provided.
A resident with a history of UTI, Type II diabetes, and paralysis was observed with an indwelling catheter bag touching the floor while seated in a wheelchair. A CNA acknowledged the infection control issue, and the DON confirmed the CNA's responsibility to prevent such occurrences, as per facility policy.
The facility exceeded the room capacity regulation by accommodating more than four residents in two rooms, with one room housing seven and another five residents. Despite this, observations showed adequate space for care, privacy curtains, and safe egress. Interviews with residents and CNAs revealed no concerns about space or care provision. A room waiver request was submitted, aligning with residents' special needs, and the Department recommended its continuation.
Failure to Follow Pain Assessment and Monitoring Protocols for Residents Receiving Opioid Pain Medications
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not adhering to physician orders and facility policies regarding pain assessment and monitoring. For one resident with a history of lumbar spinal fusion, low back pain, and end-stage renal disease, the care plan required administration of oxycodone as needed, with pain reassessment within one hour after administration. However, medication administration records showed that pain was not reassessed within the required timeframe, with follow-up assessments occurring more than one to five hours after medication was given. Both the registered nurse and the director of nursing confirmed that the facility's protocol and policy required pain reassessment within one hour, and acknowledged that this was not done as required. For another resident with multiple fractures, respiratory failure, and a history of falls, physician orders and the care plan required pain assessment and documentation every shift, as well as assessment of respiratory rate prior to administering hydromorphone. Medication administration records indicated that pain levels and respiratory rates were not consistently assessed or documented prior to medication administration on several occasions. Interviews with nursing staff and the director of nursing confirmed that these assessments were necessary and should have been documented each time pain medication was administered. The facility's policies on pain management and medication administration required licensed nurses to complete pain assessments for residents identified as having pain, administer pain medication as ordered, and re-evaluate and document the resident's pain level within one hour after medication. The failure to follow these protocols resulted in inadequate monitoring and documentation of pain management for both residents.
Improper Food Storage and Unsanitary Food Preparation Practices
Penalty
Summary
Surveyors observed that the facility failed to follow safe and sanitary food storage and preparation practices in the kitchen. Specifically, boxed food items, including rice, non-dairy creamer packets, parsley, mayonnaise, and salt, were found stored directly on the floor in the dry storage room. Additionally, a dispensing scoop was stored inside a clear storage container of salt. These practices were observed during a concurrent interview and observation with a kitchen staff member, who confirmed that the items should have been stored at least six inches off the floor and that the scoop should not be kept inside the salt container due to sanitation concerns. Further interviews with the dietary supervisor revealed that the food items were left on the floor after cleaning other portions of the dry storage area. The dietary supervisor also acknowledged that facility policy requires food to be stored six inches off the floor and that scoops should not be left inside food containers for infection control purposes. A review of the facility's policy and procedure on food storage and handling confirmed these requirements.
Failure to Provide Required Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare Part A skilled services were ending. The resident, who was admitted with multiple diagnoses including type 2 diabetes, schizoaffective disorder, major depressive disorder, hypertension, and anxiety disorder, was cognitively intact and required assistance with several activities of daily living. According to the resident's records, the last covered day for Medicare Part A services was identified, and the discharge from Medicare services was initiated by the facility before benefit days were exhausted. However, the NOMNC was not provided to the resident because she left the facility to go home. Interviews with the Business Office Manager and the Director of Nursing confirmed that the resident should have received the NOMNC, as the discharge was planned and initiated by the facility. Both staff members acknowledged that the NOMNC is necessary to inform residents of their last covered day and their right to appeal the discharge. Review of facility policy and CMS guidelines further supported the requirement to provide the NOMNC at least two days before the end of covered services, which was not done in this case.
Inaccurate MDS Assessments for Restraint Use and Bowel/Bladder Status
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to restraint use and bowel/bladder documentation. For one resident with dementia, difficulty walking, and muscle weakness, the MDS inaccurately indicated the use of trunk restraints. Observations and interviews with staff confirmed that the resident did not have restraints, and both the MDS Coordinator and Director of Nursing acknowledged the inaccuracy in the MDS documentation regarding restraint use. For another resident admitted with a history of antimicrobial resistance, urinary tract infection, acute kidney failure, and difficulty walking, the MDS assessment inaccurately documented the resident as frequently incontinent of bowel and bladder, and not on a bowel and bladder program. However, the care plan indicated the resident was continent, and interviews with the resident and staff confirmed the resident was generally able to control bowel and bladder function, with rare episodes of incontinence. The resident expressed a desire for scheduled reminders and assistance to the restroom, which was not reflected in the MDS or care plan alignment. Facility policy and procedure reviews confirmed the requirement for accurate resident assessments and the use of the Resident Assessment Instrument (RAI) process to ensure proper care planning. The discrepancies between the MDS assessments and actual resident status had the potential to result in inadequate care, as acknowledged by facility staff during interviews.
Incomplete Baseline Care Plan for Dialysis Access Site
Penalty
Summary
The facility failed to develop a complete baseline care plan for a resident admitted with end stage renal disease, hypertension, and an acquired absence of the left leg below the knee. Upon admission, the resident had a left femoral permcath in place for dialysis access, as well as arteriovenous fistulas in both upper arms. Physician orders required monitoring of the left femoral permcath site for signs of infection or complications during every shift. The resident's cognitive skills were intact, and they required partial to moderate assistance with daily activities. Despite these needs and orders, the baseline care plan created within 48 hours of admission did not include any information regarding the resident's left femoral dialysis access site. Both the registered nurse and the director of nursing confirmed that the baseline care plan was incomplete and did not address the dialysis access site, which was necessary for the resident's immediate care. Facility policy required that baseline care plans include all essential health information to ensure proper care upon admission, but this was not followed in this instance.
Failure to Develop Individualized Care Plans for Incontinence and Oxygen Use
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with specific clinical needs. For one resident with hemiplegia, hemiparesis, severe cognitive impairment, and frequent incontinence of bowel and urine, the care plan only included an intervention to administer medications as ordered and document their effectiveness. There were no additional interventions listed to address the resident's incontinence, such as assistance with toileting or changing soiled briefs. Both the MDS Coordinator and the Director of Nursing acknowledged during interviews that the care plan was insufficient and did not adequately address the resident's needs for incontinence care. For another resident with diagnoses including cough, dementia, and type 2 diabetes mellitus, and who had a physician order for oxygen administration via nasal cannula as needed to maintain oxygen saturation above 92%, the facility did not develop a comprehensive care plan to address oxygen use. The resident's Minimum Data Set indicated severe cognitive impairment and a need for substantial to maximal assistance with activities of daily living. Despite these needs and the physician's order, the care plans reviewed did not include interventions or monitoring related to oxygen therapy. The facility's policy required the development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes to meet each resident's identified needs. The lack of appropriate care planning for both residents was confirmed by staff interviews and record reviews, indicating that the facility did not follow its own policy and failed to ensure that care plans described the services necessary to maintain the residents' highest practicable well-being.
Failure to Provide Ordered Heel Protectors for At-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for a resident at risk for pressure injuries. The resident, who had diagnoses including diabetes mellitus, failure to thrive, and paraplegia, was identified as being at moderate risk for pressure ulcer development due to impaired mobility, incontinence, and poor nutrition. The care plan and physician orders specified the use of bilateral heel protectors while the resident was in bed to prevent pressure injuries. However, during observation, the resident was found in bed without the required heel protectors, with their heels instead placed on a pillow. Interviews with both an LVN and the DON confirmed that the resident should have been wearing bilateral heel protectors as per the physician's order and care plan. The facility's policy on pressure injury prevention also required staff to implement such interventions. The failure to provide the ordered heel protectors constituted a lapse in following prescribed care for a resident at risk for pressure injuries.
Failure to Provide Ordered Padded Side Rails for Seizure Precautions
Penalty
Summary
The facility failed to follow physician orders for a resident with a seizure disorder by not providing bilateral padded side rails as required for seizure precautions. The resident, who had diagnoses including diabetes mellitus, failure to thrive, and paraplegia, was admitted and readmitted with a care plan that included interventions to protect the resident from injury during seizures. Physician orders specifically directed the use of bilateral padded side rails, and the facility's policy also listed side rail padding as a seizure precaution. Despite these orders and policies, observations on multiple occasions revealed that the resident's bedrails did not have any padding. Interviews with nursing staff and the Director of Nursing confirmed that the resident had an order for padded side rails, and that the padding was necessary to protect the resident from injury during a seizure. The facility's failure to implement these precautions constituted a deficiency in providing a safe environment and adequate supervision for the resident.
Deficient Urinary and Bowel Care Services for Two Residents
Penalty
Summary
The facility failed to provide appropriate urinary and bowel care services for two residents. For one resident, who was admitted with a history of resistance to multiple antimicrobial drugs, urinary tract infection (UTI), acute kidney failure, and difficulty walking, the care plan indicated the resident was continent of bowel and bladder with a goal to keep the resident dry, clean, and comfortable. However, the Minimum Data Set (MDS) assessment reflected frequent incontinence and did not offer a bowel and bladder program. The resident reported awareness of the need to urinate and have bowel movements, rarely soiled herself, and expressed embarrassment after an incident of incontinence, stating that scheduled reminders and assistance would be helpful. Staff interviews confirmed that the care plan and MDS were inconsistent and that the resident should have been started on a bowel and bladder program to prevent UTIs and skin breakdown, as outlined in facility policy. For the second resident, who was admitted with diagnoses including a displaced avulsion fracture, difficulty walking, muscle weakness, and obstructive and reflux uropathy, the care plan required that the indwelling catheter bag and tubing be positioned below the level of the bladder. During observation, the resident's catheter tubing was found to have a large dependent loop containing yellow liquid with sediment, which had backflowed to the urine drainage port. A registered nurse confirmed that the tubing was improperly looped and that urine was not draining correctly, which could lead to infection. The DON stated that catheter tubing should always remain straight to prevent UTIs, especially for residents with a history of obstruction. Facility policies reviewed indicated the importance of providing appropriate treatment and services to minimize UTIs, restore bowel and bladder function, and prevent skin breakdown. The policies also specified that catheter collection bags should be kept below the level of the bladder to prevent backflow. The observed failures in care for both residents were inconsistent with these policies and resulted in deficiencies in providing necessary urinary and bowel care services.
Failure to Follow Oxygen Therapy Protocols for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care services for two residents by not following established protocols for oxygen therapy. For one resident with COPD and heart failure, the physician ordered oxygen at four liters per minute as needed, and the care plan required humidification to prevent symptoms of poor oxygen absorption. Observations revealed that the resident's oxygen humidifier bottle was nearly empty on one occasion and completely empty on another, despite the resident using oxygen continuously and stating a need for humidification. A nurse confirmed the humidifier bottle was empty and acknowledged that lack of humidification could lead to nasal dryness and bleeding. The Director of Nursing stated that humidifier bottles should be checked daily and changed before running out, in line with facility policy. For another resident with respiratory failure and a history of fractures, the physician ordered continuous oxygen therapy via nasal cannula. The facility's policy required that nasal cannulas be changed every seven days and labeled with the date of change to prevent infection. During an observation, the resident's nasal cannula was not labeled with the date it was last changed. A nurse confirmed the cannula should be labeled and changed weekly, and the DON reiterated the importance of labeling to prevent bacterial growth and respiratory infections. The facility's own policies and procedures for oxygen therapy were not followed in both cases. The humidifier bottle for one resident was allowed to run empty, and the nasal cannula for another resident was not labeled as required. These lapses were confirmed by staff interviews and direct observation, and were contrary to the facility's written protocols for respiratory care.
Failure to Ensure Accurate Assessment and Monitoring of Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end stage renal disease who required hemodialysis. The resident was admitted with a history of ESRD, hypertension, and a left leg amputation, and had a left femoral artery permcath as the current dialysis access site. However, the clinical admission form did not indicate that the resident underwent dialysis, and the admission progress note incorrectly documented the dialysis access site as a right upper arm AVF instead of the left femoral permcath. This resulted in inaccurate documentation of the resident's dialysis needs and access site. Further review revealed that the facility did not complete thorough pre and post dialysis assessments for the resident on multiple occasions. Specifically, assessment forms for several dialysis dates were incomplete and did not include required evaluations of the dialysis access site after treatment. Both the RN and DON confirmed that licensed staff were required to assess the dialysis access site before and after each dialysis session, but this was not done as required. The facility's own policy mandated daily assessment and documentation of the vascular access site, as well as completion of pre and post dialysis evaluations by a licensed nurse. Observations and interviews confirmed that the resident was aware of her dialysis schedule and access site, but facility documentation and assessments did not accurately reflect her current treatment or provide the necessary monitoring. The lack of accurate admission documentation and incomplete pre and post dialysis assessments led to a failure in ensuring safe and appropriate dialysis care for the resident.
Non-Compliance with Resident Room Occupancy Limits
Penalty
Summary
The facility failed to ensure that two rooms did not accommodate more than four residents, as required by regulations. Review of the facility's room waiver request letter indicated that these rooms exceeded the four-bed limit, with one room containing seven beds and another containing five beds. The waiver letter stated that the rooms had adequate space for each resident and that the arrangement would not adversely affect residents' health and safety. Observations confirmed that each resident had privacy curtains, working call-lights, a dresser, and a bedside table. During multiple observations, nursing staff were seen providing care with adequate space in the affected rooms. Interviews with a resident and a CNA revealed that neither had concerns about the available space, and both felt there was sufficient room for movement and care activities. Despite these observations, the rooms did not comply with the regulation limiting occupancy to four residents per room.
Failure to Monitor Assistive Signaling Devices
Penalty
Summary
The facility failed to ensure the proper monitoring of assistive signaling devices, specifically bed and wheelchair alarms, for a resident with dementia and mobility issues. The resident was admitted with diagnoses including dementia, difficulty walking, and generalized muscle weakness, and had a history of falls. Physician orders were given to apply a bed alarm on December 23, 2024, and a wheelchair alarm on January 3, 2025, for the resident's safety. However, the facility did not begin monitoring the placement and functionality of these alarms until March 18, 2025, which was a significant delay from when the alarms were initially applied. Interviews with facility staff, including licensed vocational nurses and the director of nursing, confirmed that the monitoring of these alarms only started on March 18, 2025. The facility's policy required that the placement and functionality of signaling devices be verified every shift and documented in the resident's medical record. The lack of monitoring had the potential for the alarms to malfunction without the facility's knowledge, increasing the risk of the resident leaving the bed or wheelchair unnoticed, which could lead to accidents.
Failure to Administer Adequate Oxygen Therapy
Penalty
Summary
The facility failed to administer adequate supplemental oxygen to a resident in accordance with professional standards of practice. The resident, who had a history of congestive heart failure and hypertension, was found with an altered level of consciousness and an oxygen saturation of 64%, which is significantly below the normal range. Despite the critical condition, the resident was initially given only four liters of oxygen via a nasal cannula, which was insufficient for the resident's needs. The paramedics later found the resident cyanotic and cold to the touch, with an oxygen saturation of 70% after receiving the nasal cannula oxygen. The paramedics promptly placed the resident on a non-rebreather mask at 15 liters per minute, which increased the resident's oxygen saturation to 87%. Interviews with the nursing staff revealed a lack of documentation regarding the amount of oxygen administered and the device used, which was acknowledged by the Director of Nursing as a critical oversight. The facility's policy and procedures require that progress notes reflect changes in the resident's condition and that oxygen therapy be administered safely to meet resident needs, which was not adhered to in this case.
Failure to Provide Documents in Residents' Preferred Language
Penalty
Summary
The facility failed to ensure that two residents and their families were fully informed and understood the documents they signed, specifically the Assisted Living Waiver (ALW) forms and consents. Both residents, who were cognitively intact, required assistance with various activities of daily living and preferred communication in their own language. Despite this, the ALW forms and consents were provided in English, a language the residents did not understand, and no interpreter was used at the time of signing. This resulted in the residents and their families being unaware of the contents of the documents they signed. Interviews with the residents and their family members revealed that they did not remember what they signed and were not provided copies of the documents. The facility's administrator, who spoke the residents' language, claimed to have interpreted the documents during the signing process. However, the facility's policies on resident rights and translation services were not adhered to, as the residents were not informed in a language they could understand, nor were they provided with competent translation services as required by the facility's procedures.
Failure to Provide Timely Notice of Discharge
Penalty
Summary
The facility failed to provide a Notice of Proposed Transfer and Discharge to a resident who was scheduled for a planned discharge to a lower level of care. The resident, who was cognitively intact and required supervision and assistance with various activities of daily living, was originally admitted in 2017 and readmitted with diagnoses including diabetes, reduced mobility, and difficulty in walking. The interdisciplinary team met with the resident and a family member to discuss the discharge plan, but the required notice was not given. The Director of Nursing acknowledged during an interview that the notice should have been provided to the resident as soon as the discharge date was known. The facility's policy requires that such notice be given 30 days prior to discharge or as soon as practicable, and a copy should be kept in the medical record. However, this procedure was not followed, resulting in the deficiency.
Failure to Post Actual Staff Hours
Penalty
Summary
The facility failed to comply with federal requirements by not posting the actual daily hours worked by staff in an area accessible to the public for four out of six days in June 2024. Observations made on June 3rd, 4th, 5th, and 6th revealed that the Census and Direct Care Service Hours Per Patient Day (DHPPD) displayed in the facility lobby only reflected the projected working hours of staff rather than the actual hours worked. This discrepancy was confirmed during an interview with the Director of Staff Development (DSD), who acknowledged that the actual hours were kept in a separate binder and not posted as required. The facility's policy, titled 'Nursing Department - NHPPD Staffing Audit Guidelines,' dated March 14, 2024, mandates the posting of actual nursing hours performed by direct caregivers per patient day. The DSD emphasized the importance of posting actual nursing hours to ensure patient safety and adequate staffing for the current patient census. The failure to provide residents, family, or visitors with the actual number of staff could lead to feelings of unease among them, as they would not have access to accurate staffing information.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential delay in care and services. Resident 10, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was found with the call light on the floor, out of reach. The resident's care plan emphasized the importance of having the call light within reach due to the risk of falls and dependency on staff for activities of daily living. During an observation, a Licensed Vocational Nurse confirmed that the call light was not accessible to Resident 10, acknowledging that it should be within reach to allow the resident to call for help. Similarly, Resident 113, admitted with diagnoses including alcohol and stimulant abuse and muscle weakness, was observed with the call light hanging from the wall, far from reach. The resident was unaware of the call light's location, and a Certified Nursing Assistant confirmed its inaccessibility. The facility's Director of Nursing stated that call lights are required to be accessible at all times, and the facility's policy mandates that call cords be placed within residents' reach. These observations highlight the facility's failure to adhere to its policy, potentially impacting residents' ability to request assistance.
Failure to Revise Care Plans for Discontinued Treatments
Penalty
Summary
The facility failed to revise care plans for two residents, leading to a deficiency in care planning. Resident 20's care plan was not updated to reflect the discontinuation of antibiotic therapy. The resident was initially prescribed Ceftriaxone Sodium Injection for a urinary tract infection and later switched to Keflex. Despite the completion of these antibiotic courses, the care plan continued to indicate that the resident was on antibiotic therapy. This oversight was confirmed during a review of the resident's medical records and interviews with the Minimum Data Set Coordinator and the Director of Nursing. Similarly, the care plan for Resident 47 was not revised following the removal of an indwelling catheter. The resident was admitted with a urinary tract infection and had an indwelling catheter in place. The physician ordered the removal of the catheter, but the care plan was not updated to reflect this change. Observations and interviews confirmed that the catheter had been removed, yet the care plan still indicated its presence. The Director of Nursing acknowledged that the care plan should have been revised to accurately reflect the resident's current status. The facility's policy on comprehensive person-centered care planning requires that care plans be reviewed and revised after each assessment and upon changes in a resident's condition. The failure to update the care plans for these residents placed them at risk for inconsistent care, as the plans did not accurately reflect their current medical needs and treatments.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not rotating the site for administration of a subcutaneous injection of Basaglar, a long-acting insulin. This deficiency was identified for one of the three sampled residents, who was diagnosed with Type 1 diabetes and required insulin administration. The physician's order specifically indicated that the injection sites should be rotated to prevent complications, but this was not adhered to. The resident, who had intact cognition and required moderate assistance with daily activities, received the Basaglar injection in the same site on the right arm for four consecutive days. This practice was confirmed during a review of the resident's medical record with the MDS Coordinator, who acknowledged the need for site rotation to prevent skin complications. The Director of Nursing also confirmed that the licensed nurses were required to rotate the injection sites as per the physician's order and the facility's policy on subcutaneous injections.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication by not following the physician's order to discontinue Enoxaparin, a blood thinner, on a specified date. The resident continued to receive the medication for several days without a physician's order, which placed the resident at risk for adverse effects such as internal bleeding. The Director of Nursing (DON) acknowledged the oversight, stating that she forgot to follow through on the pharmacy's recommendation to discontinue the medication. The resident, who was initially admitted with a fracture of the left femur and other mobility issues, had intact cognition and required assistance with certain activities. The resident's care plan included administering Enoxaparin as ordered and monitoring for adverse reactions. Despite a pharmacist's note recommending the discontinuation of Enoxaparin, the medication was administered daily until the oversight was discovered during a surveyor interview. The facility's policy indicated that changes in medication orders should be documented and carried out promptly, which did not occur in this case.
Failure to Serve Therapeutic Diet as Prescribed
Penalty
Summary
The facility failed to ensure that a therapeutic diet was served according to the Physician's Order for a resident diagnosed with dementia, muscle weakness, and requiring assistance with personal care. The Physician's Order specified a no added salt diet, mechanical soft texture, and nectar thick consistency liquids due to mild signs of dysphagia. Despite these orders, the resident was observed consuming coffee with a thin consistency, which was not in compliance with the prescribed nectar thick liquid requirement. During observations and interviews, it was revealed that the staff served the resident coffee with a thin consistency instead of the required nectar thick consistency. The Certified Nursing Assistant (CNA) acknowledged the error but was unaware of which staff member served the coffee. Both the Registered Dietician and the Director of Nursing confirmed the necessity of following the Physician's Order for nectar thick liquids to prevent risks such as choking and aspiration. The facility's policy on therapeutic diets emphasized the importance of adhering to physician orders, which was not followed in this instance.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide a dycem, a non-slip mat, to a resident who required it for eating, as part of their adaptive equipment needs. This deficiency was identified for a resident with hemiplegia, hemiparesis, diabetes Type II, and muscle weakness, who was admitted on 8/8/2023. The resident's care plan, revised on 8/9/2023, specified the need for a divided plate and dycem at each meal to assist with self-feeding. Despite this, observations on 6/5/2024 revealed that the resident was not provided with a dycem during lunch, although a divided plate was present. The resident confirmed that the blue mat, previously used to prevent the food tray from slipping, was missing and had not been replaced. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed the importance of providing adaptive equipment to the resident to support independent eating. The facility's policy, reviewed on 3/14/2024, indicated that adaptive equipment should be provided by the occupational therapist to the dietary department for daily meal services. However, a review of the Medical Administration Record for May 2024 showed no documentation of the adaptive equipment being provided at each meal, indicating a lapse in following the prescribed care plan and physician's orders.
Catheter Bag Touching Floor in LTC Facility
Penalty
Summary
The facility failed to ensure that an indwelling catheter bag was not touching the floor for one of the residents, which could potentially lead to a urinary tract infection. The resident, who was admitted with diagnoses including a urinary tract infection, Type II diabetes mellitus, and paralysis on the right side of the body, required assistance with daily activities. During an observation, the resident was seen sitting in a wheelchair with the catheter bag hanging and touching the floor. A Certified Nursing Assistant acknowledged that the catheter bag should not be touching the floor due to infection control concerns. The Director of Nursing confirmed that the CNA should have ensured the catheter bag was not in contact with the floor, as per the facility's policy and procedure on catheter care.
Room Capacity Exceeded in Two Resident Rooms
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to four, as two rooms were found to accommodate more than the allowed number of residents. Specifically, one room housed seven residents, and another housed five, exceeding the regulatory limit. Despite this, observations indicated that nursing staff had adequate space to provide care, and privacy curtains were available for residents. Additionally, the rooms had two modes of egress, ensuring safety. Interviews with residents and CNAs revealed no concerns regarding space adequacy or care provision. A room waiver request was submitted, indicating that the room arrangements were in line with the residents' special needs and did not adversely affect their health or safety. The Department recommended the continuation of the Room Waiver Request.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7,011 citations issued within 25 miles in the last 12 months — including the 35 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Park Skilled Nursing And Wellness Center | 0.9 mi | ★★★★★ | 22 | 0 |
| Huntington Healthcare Center | 1.5 mi | ★★★★★ | 22 | 0 |
| York Healthcare & Wellness Centre | 1.8 mi | ★★★★★ | 1 | 0 |
| Kei-ai Los Angeles Healthcare Center | 2 mi | ★★★★★ | 37 | 0 |
| College Vista Post-acute | 2.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.